TAPS ANNUAL CONFERENCE

1. TAPS ANNUAL CONFERENCE “Enhancing the Patient Experience Through Advocacy: Connecting the dots for better patient outcomes” September 25– 26, 2014 DoubleTree By Hilton Austin, Austin, Texas REGISTRATION FORM (One person per form – photocopy as needed) Name Credentials Title Friends Call Me Organization Address City State Zip Phone ( ) Cell Phone ( ) Fax ( ) E-mail Special needs per the Americans with Disabilities Act? Yes No Special diet needs? Describe Yes No Is this your first TAPS conference? Yes No REGISTRATION FEES Member Non-Member Reg Fee Early Bird Special before 8/1/14 $250 $350 Full registration after 8/1/14 $300$375 One Day Only & Guest Registration Thursday (includes lunch & networking event) $125 $200 Friday (includes lunch) $125 $200 Guest ticket: Thursday Networking Event$ 35 x Sponsorship Registration: Company Membership Dues (9/1/13 – 8/31/14) Active Member (employed by a health care institution) $ 95 Associate Member (vendors, consultants, others) $150 Affiliate Member (students, educators, non-voting) $ 50 [TAPS tax ID # 03-0467983] TOTAL DUE TO TAPS$ Please let us know if you will attend the following (check all that apply): Networking Event, Thursday, September 25, 2014 Lunch on Thursday, September 25, 2014 Lunch on Friday, September 26, 2014 PAYMENT INFORMATION My check # payable to TAPS in the amount of $is enclosed. Please charge my: Visa MasterCard Am Express Exp Date / Card Number Verification Code Billing Zip Code Print cardholder’s name Signature Please email or fax this form by September, 20, 2014 Kyle Whitaker, TAPS Executive Director P.O. Box 121959 Arlington, TX 76012 Phone: 512.508.8277; Fax: 512.355.1930 TAPSAdmin@TAPS-online.org