CCHF Conference Registration

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Student Scholarship Info

2019 CCHF Conference Registration

March 28-30, 2019
Covington, KY

…a charming city across the river from downtown Cincinnati, OH

Registration Types:

$325 - General
$285 - CCHF Partner Clinic Employees
$265 - Spouse
$265 - Student (non-volunteer)
$ 65 - Healthcare Student Scholarship (Subject to CCHF approval and requires 6-8 Volunteer Hours during Conference.)
$ 50 - COVINGTON (by permission only)
$120 - Day Rate
$ 95 - CE Credit - Medical (AMA PRA) or Dental (PACE AGD)

Meals provided: Free breakfast at the conference hotels, dessert buffet during CCHF Late Night and lunch on Friday.

Who should fill out this form? Every conference attendee (including students requesting scholarships, workshop presenters and exhibitors)

Registration Type - please select

Registration Type

Is this your 1st CCHF conference?

YesNo

Contact Information

First Name

Last Name

Credentials

(MD,DO,RN,PhD,BSW,etc.)

Gender?

What do you prefer to be called?

Preferred Email

Personal Email

Work Email

Preferred Phone

Work Phone

Mobile Phone

Home Phone

Address

City

State

Zip

Food Allergies?

If you have food allergies please note them here. We will do our best to accommodate you.

Do you work for a partner organization? Are you a student? Work for a different organization?

Your job/position title

Organization Name

Name of Clinic (if not listed on drop-down menu)

Street - Clinic

City - Clinic

State - Clinic

Zip Code - Clinic

Phone Number - Clinic

Website - Clinic

Your Organization Name

Street - Organization

City - Organization

State - Organization

Zip Code - Organization

Phone - Organization

Website - Organization

Is your clinic or organization paying for your registration?

If yes, your organization will be billed for your fees.

STUDENT Information

Students/Residents, please provide your permanent address (Not your dorm or university PO Box)

Permanent Street

Permanent City

Permanent State

Permanent email address

Placement, Residency or University

Full school name,please

Expected Graduation Date

Month/Year

Area of Study/Specialty

(FNP, BS-PreMed, MD, DO, Nursing, DDS, etc.)

Are you requesting scholarship funding to help with conference expenses?

Medical students may qualify for a registration rate of $65. If you are requesting a scholarship (and are approved), please submit that fee upon completion of this form. (Non-scholarship student rate is $265). Scholarship recipients will be expected to volunteer for up to 7 hours during the conference.

Are you willing to serve as a volunteer for up to 7 hours during the conference?

Volunteers are required to attend a training meeting. Please select your preferred meeting time.

Volunteers will serve in various areas. Please indicate one or two areas that you prefer. Your choice of service area cannot be guaranteed but we will make every effort to accomodate your request.

Are you currently associated with a health care organization that ministers to underserved people?

Name of Organization

How did you hear about CCHF?

Estimated Cost to Attend

Travel costs

$

List a basic summary of your travel expenses: gas, meals, airfare. (Do not include hotel expense).

List number of nights you will need a hotel room. The conference begins on Thursday at 1pm and ends on Saturday at 2:30pm. CCHF will handle your hotel arrangements once your scholarship request is approved.

Other costs

$

If you have other costs please explain them here.

Total Amount of Scholarship Requested

$

Scholarships are generously funded by CCHF members and member organizations that recognize the value of investing in young health professionals like you. Scholarship awards are intended to remove financial hurdles by covering travel expenses. Travel expense checks will be available when you arrive at the conference.

Sign up for the CCHF Conference Prayer updates and join with others who are praying for the conference.

Please add me to the list

Email Address for Prayer Emails

Donation Type

Paypal_Hidden_Fields

Contact Information

Already Registered? Your next step is to...

Book Your Hotel

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