2025 EM Summit Registration Form

Contact Person

Please provide the contact information for the person placing the registration order. This ensures invoices and receipts are delivered correctly.

Name(Required)

Salutation First Name Last Name

Title(Required)

Email(Required)

Phone(Required)

Health Center/Organization(Required)

Other Health Center/Organization(Required)

Registration

You may register up to five (5) Attendees at one time.

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Member Registration(Required)

Member Registration

Member Quantity(Required)

Please enter a number from 0 to 5.

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Non-Member Registration(Required)

Non-Member Registration

Non-Member Quantity(Required)

Please enter a number from 0 to 5.

Total

Coupon

Member Code: EMBOGO / Non-Member Code: NMBOGO

Billing

How would you like to pay?(Required)

Check

Credit Card

Total

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

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.

2025 Health Center Emergency Management Summit Registration

Contact Person

Registration

Attendee Information

Billing

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.