October 8-9, 2018

Palo Alto, California

Lean Healthcare Academic Conference at Stanford

REGISTRATION FORM

By completing this registration form you have read, understood and agree to all terms and conditions of bookings including cancellation policies, privacy statement and security requirements as stated on the Conference website. The information submitted will be reproduced in the delegate list at the Conference and be used for all mailings. Please ensure the information you complete is correct.


NOTE: All fees listed are exclusive of sales tax and this will be shown as a separate line cost. All costs are shown in USD. Confirmation of your registration will be sent by return email once your online booking is completed.

The Conference Organizer
Email: lisa@lean.org.au

* denotes a mandatory requirement for completion to confirm your registration

A. DELEGATE DETAILS *

DELEGATE
TITLE*            
GIVEN NAME* FAMILY NAME*
ORGANIZATION*
POSITION*
STREET ADDRESS*
CITY/SUBURB*
STATE  
TELEPHONE
ZIP CODE*
Country*
MOBILE PHONE*
EMAIL*
PREFERRED NAME ON NAME BADGE*   

B. REGISTRATION FEES *

Organizations registering five or more full price attendees will receive the sixth registration free of charge. Please note that each registrant MUST be from the same organization to be eligible

Visit the website to view delegate entitlements.
NOTE: All fees are in USD.

REGISTRATION CATEGORY PRICE CATEGORY
  EARLY BIRD
Until September 20		 STANDARD
After September 20		 QUANTITY TOTAL
1. Two Day Registration – Monday, October 8 & Tuesday, October 9
$
2. Student/Trainee (limited spaces available, student/trainee ID required at registration)
$
3. One Day Registration
$
4. Half Day Site Visit - Stanford Children's Health (limited spaces available) Wednesday, October 10 - 7.30am - 12.30pm
$
B. SUB-TOTAL REGISTRATION FEES: $

C. SOCIAL PROGRAM

The Welcome Reception is included in the Registration Fee for all Delegates, excluding Site visit only Registrations.
Please indicate if you will be attending: Yes No

If you require additional tickets only, please complete this section:


D. SPECIAL NEEDS/DIETARY REQUIREMENTS

If you have specific dietary requirements please indicate below. We will endeavour to cater to your needs but this may not be possible in all cases.

Please provide details of YOUR special needs/dietary requirements

Please provide details of YOUR GUEST/S special needs/dietary requirements


Please note: If you have selected Kosher or Halal, you will be provided with a vegetarian meal. Should you require alternative meal arrangements please contact the Conference Organizer.

E. PRIVACY

YES – please include my details as given in this form (and any subsequent amendment) in the Delegate List produced for the Conference which may be supplied to organizing bodies, sponsors, exhibitors and all delegates attending the Conference.

No, please do not include my details in the Delegate List.


F. PAYMENT AND CONDITIONS

NOTE: All fees are in USD and are exclusive of sales tax. Sales tax will be shown as a separate line cost.
SECTION B REGISTRATION FEES $
SECTION C SOCIAL PROGRAM $
    SALES TAX:7.5% $
  TOTAL: $

G. TOTAL FEES

Please charge the total amount above to the following credit card:
Mastercard Visa Card

Please note all transactions by credit card will appear on your statement as payment to: Lucile Packard Children's Hospital
Payment Information
Card Holder Name* Card Number* CVC*
Card Expiry*    



H. CANCELLATION & REFUND POLICY

Cancellations received in writing to the Conference Organizer by September 10, 2018 will be accepted and all fees refunded less a $100 administrative fee. Cancellations received after this date cannot be accepted and cannot be refunded, however transfer of your registration to another person is acceptable. The full name and details of the person that will replace you must be advised in writing to the Conference Organizer's Office prior to the Conference. No refunds can be made for non-attendance at the Conference.


I. ENQUIRIES

Enquiries regarding registration for the Lean Healthcare Academic Conference at Stanford

Email: lisa@lean.org.au