2025 Health Center Emergency Management Summit Registration Step 1 of 4 25% Contact PersonPlease provide the contact information for the person placing the registration order. This ensures invoices and receipts are delivered correctly.Name(Required) Salutation Mr.Mrs.MissMs.Dr.Prof.Rev. First Name Last Name Title(Required)Email(Required) Phone(Required)Health Center/Organization(Required)Choose your Health Center from this list:AGAPE COMMUNITY HEALTH CENTERAZA HEALTHBANYAN COMMUNITY HEALTH CENTERBOND COMMUNITY HEALTH CENTERBORINQUEN MEDICAL CENTERSBREVARD HEALTH ALLIANCEBROWARD COMMUNITY & FAMILY HEALTH CENTERSCAMILLUS HEALTH CONCERNCARE RESOURCE COMMUNITY HEALTH CENTERSCENTER FOR FAMILY AND CHILD ENRICHMENTCENTERPLACE HEALTHCENTRAL FLORIDA HEALTH CARECITRUS HEALTH NETWORKCOMMUNITY HEALTH CENTERS, INC.COMMUNITY HEALTH OF SOUTH FLORIDACOMMUNITY HEALTH NORTHWEST FLORIDAEMPOWER-UEVARA HEALTHFAMILY HEALTH CENTERS OF SOUTHWEST FLORIDAFAU/NCHA COMMUNITY HEALTH CENTERFLORIDA COMMUNITY HEALTH CENTERS, INC.FOUNDCAREGENESIS COMMUNITY HEALTHGRACEPOINTHEALTH CARE DISTRICT COMMUNITY HEALTH CENTERHEALTHCARE NETWORKHEART OF FLORIDA HEALTH CENTERJESSIE TRICE COMMUNITY HEALTH SYSTEMLANGLEY HEALTH SERVICESLEE COMMUNITY HEALTHCAREMCR HEALTHMIAMI BEACH COMMUNITY HEALTH CENTERSNEIGHBORHOOD MEDICAL CENTERNORTH FLORIDA MEDICAL CENTERSFAMILY HEALTH SOURCEORANGE BLOSSOM FAMILY HEALTH CENTEROSCEOLA COMMUNITY HEALTH SERVICESPALMS MEDICAL GROUPPANCARE OF FLORIDAPINELLAS COUNTY HEALTH AND HUMAN SERVICESPREMIER COMMUNITY HEALTHCARE GROUPRURAL HEALTH NETWORK OF MONROE COUNTYSMA HEALTHCARESULZBACHERSUNCOAST COMMUNITY HEALTH CENTERSTAMPA FAMILY HEALTH CENTERSTREASURE COAST COMMUNITY HEALTHTRUE HEALTHWHOLE FAMILY HEALTH CENTEROTHER HEALTH CENTER/ORGANIZATIONOther Health Center/Organization(Required) RegistrationYou may register up to five (5) Attendees at one time.This field is hidden when viewing the formMember Registration(Required) Member Registration Member Quantity(Required)Please enter a number from 0 to 5.This field is hidden when viewing the formNon-Member Registration(Required) Non-Member Registration Non-Member Quantity(Required)Please enter a number from 0 to 5.Total CouponMember Code: EMBOGO / Non-Member Code: NMBOGO Attendee InformationPlease ensure email addresses and phone numbers are direct for each attendee. This ensures access to Communication Updates and Event App Access.Attendee # 1(Required) Salutation Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Name Last Name Attendee #1 Academy Day Selection(Required) Business Continuity Planning (Limited Seating) Hazard Specific Planning (Limited Seating) No Preference (Wherever space is available) Attendee #1 Title(Required)Attendee #1 Email(Required) Attendee #1 Phone(Required)Attendee #1 Dietary Restrictions?Attendee # 2(Required) Salutation Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Name Last Name Attendee #2 Academy Day Selection(Required) Business Continuity Planning (Limited Seating) Hazard Specific Planning (Limited Seating) No Preference (Wherever space is available) Attendee #2 Title(Required)Attendee #2 Email(Required) Attendee #2 Phone(Required)Attendee #2 Dietary Restrictions?Attendee # 3(Required) Salutation Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Name Last Name Attendee #3 Academy Day Selection(Required) Business Continuity Planning (Limited Seating) Hazard Specific Planning (Limited Seating) No Preference (Wherever space is available) Attendee #3 Title(Required)Attendee #3 Email(Required) Attendee #3 Phone(Required)Attendee #3 Dietary Restrictions?Attendee # 4(Required) Salutation Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Name Last Name Attendee #4 Academy Day Selection(Required) Business Continuity Planning (Limited Seating) Hazard Specific Planning (Limited Seating) No Preference (Wherever space is available) Attendee #4 Title(Required)Attendee #4 Email(Required) Attendee #4 Phone(Required)Attendee #4 Dietary Restrictions?Attendee # 5(Required) Salutation Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Name Last Name Attendee #5 Academy Day Selection(Required) Business Continuity Planning (Limited Seating) Hazard Specific Planning (Limited Seating) No Preference (Wherever space is available) Attendee #5 Title(Required)Attendee #5 Email(Required) Attendee #5 Phone(Required)Attendee #5 Dietary Restrictions? BillingHow would you like to pay?(Required) Check Credit Card Total Credit Card(Required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name Billing Address(Required) Street Address City State / Province / Region ZIP / Postal Code All requests for refund must be made in writing to Nicole Rechner at nrechner@fachc.org on or before Friday, May 2nd, 2025. No refunds will be issued after this date. All eligible refund requests will be subject to a $50 administrative fee. Substitutions are welcomed and strongly encouraged.(Required) I acknowledge and agree. For orders placed using a Scholarship Code, cancellations after May 2nd and no-shows will incur a $50 fee. This is to ensure scholarship opportunities remain accessible to all Health Centers. Substitutions are welcomed and strongly encouraged.(Required) I acknowledge and agree. If you have questions or need assistance registering for the Emergency Management Summit, please reach out to FACHC Event Coordinator, Nicole Rechner at nrechner@fachc.org.
