Small Rural Hospital Conference
Registration Form
Please use this form to register for the Small Rural Hospital Conference (November 17 & 18, 2009).
Use one form per person. E-mail completed form to [email protected]
Name:
(as you wish it to appear on
your name badge)
Title:
Organization:
Mailing Address:
City:
State:
Phone:
Zip:
Email*:
*Please note: VRHA meeting notices, weekly updates, etc., will arrive by e-mail unless you specifically request to
receive them in another format.
Registration Fees
Please check the appropriate registration category
SHIP facility staff
Non-SHIP
Registration Category
(registration must be
received by October 23)
Full conference
Tuesday only
(includes lunch)
Wednesday only
(includes lunch
(registration must be
received by October 23)
Any Registration Received
After October 23
Free
$150
$200
Free
$75
$125
Free
$75
$125
___ Yes – I will register for the VAFC/VRHA Joint Conference
(registration deadline: October 15)
___ No – I will not be registering for the VAFC/VRHA Joint Conference
Method of Payment
please check one
SHIP facility staff – no charge if received by October 23
Please bill to:
Name
Organization
Mailing Address
City/State/ZIP
Questions? Call 540-231-7923 or e-mail [email protected]
Make checks payable to VRHA and mail to:
VRHA  2265 Kraft Drive  Blacksburg  Virginia  24060