Organization Name:
_____________________________________________________________ Contact Person:
_____________________________________________________________ Address:
_____________________________________________________________ City, State, Zip:
_____________________________________________________________ Phone #:
_____________________________________________________________ E­mail:
_____________________________________________________________ Version of Enterprise EHR + HF # _________________________________________________________ Registration Category
2015­2016 Membership paid for Organization Not a member for 2015­16, but would like to become a member for 2016­17. Dues must be paid on or before registration Non Paying CRUG Member, but would like to attend the CRUG Spring Forum GUEST PASS ­ ex. Spouse, Friend for the Evening Event. This includes meal, entertainment and beverage tickets Early Registration ­ Received on or
before ​
January 31, 2016
Late Registration – Received after
January 31 and should be received on or
before ​
March 16, 2016
$300 $50 $350 $50 $200 $200 $250 $250 Attendee Name (Please Print) E­mail Address Please use additional registration forms if needed TOTAL PAYMENT Phone Number Registration Fee You may email (​
brendak@mankato­clinic.com​
) your registration form in advance. Mail your completed payment form with payment* to: Brenda Kopischke, EHR – Mankato Clinic 1421 Premier Drive Mankato, MN 56002 ​
Re: 2016 Spring Forum OFFICE USE: *​
Important Note:​
Please make sure checks are payable to: Central Region Users Group or CRUG Payment Received: □ Check □ Credit Card Date: