2026 FACHC Maternal Health Convening Step 1 of 4 25% Which Organization are you with?Health Center / Organization(Required)Choose your Health CenterAGAPE COMMUNITY HEALTH CENTERAZA HEALTHBANYAN COMMUNITY HEALTH CENTERBIG BEND HOSPICEBOND COMMUNITY HEALTH CENTERBORINQUEN HEALTH CARE CENTERBREVARD HEALTH ALLIANCEBROWARD COMMUNITY AND FAMILY HEALTH CENTERSC.L. BRUMBACK PRIMARY CARE CLINICSCAMILLUS HEALTH CONCERNCARE RESOURCE COMMUNITY HEALTH CENTERSCENTER FOR FAMILY AND CHILD ENRICHMENTCENTERPLACE HEALTHCENTRAL FLORIDA HEALTH CARECITRUS HEALTH NETWORKCOMMUNITY HEALTH CENTERS, INC.COMMUNITY HEALTH NORTHWEST FLORIDACOMMUNITY HEALTH OF SOUTH FLORIDAEMPOWER UEVARA HEALTHFAMILY HEALTH CENTERS OF SW FLORIDAFAMILY HEALTH SOURCEFLORIDA COMMUNITY HEALTH CENTERS, INC.FOUNDCAREGRACEPOINT WELLNESSGENESIS COMMUNITY HEALTHHEALTHCARE NETWORK OF SW FLORIDAHEART OF FLORIDA HEALTH CENTERI.M. SULZBACHER CENTER FOR THE HOMELESSJESSIE TRICE COMMUNITY HEALTH SYSTEMLANGLEY HEALTH SERVICESLEE MEMORIAL HEALTH SYSTEMMCR HEALTHMIAMI BEACH COMMUNITY HEALTH CENTERNEIGHBORHOOD MEDICAL CENTERNEW RIVER HEALTH CENTER / UNION COUNTYNORTH FLORIDA MEDICAL CENTERSORANGE BLOSSOM FAMILY HEALTHOSCEOLA COMMUNITY HEALTH SERVICESPALMS MEDICAL GROUPPANCARE OF FLORIDAPINELLAS HEALTH & HUMAN SERVICESPREMIER COMMUNITY HEALTHCARE GROUPRURAL HEALTH NETWORK OF MONROE COUNTY FLORIDASMA HEALTHCARESUNCOAST COMMUNITY HEALTH CENTERSTAMPA FAMILY HEALTH CENTERSTREASURE COAST COMMUNITY HEALTHTRUE HEALTHWALTON COUNTY HEALTH DEPT.WHOLE FAMILY HEALTH CENTEROTHER HEALTH CENTER / ORGANIZATIONOther Health Center / Organization Name(Required) Ticketing Information:Please select the number of Attendees that you need to register. If you do not see any ticketing options below, please use the "PREVIOUS" button to go back and make sure you've selected your Health Center or Organization from the Drop Down List.Quantity - Member TicketsYou may register up to 5 guests.Maternal Health - Member Tickets Price: Quantity - Non-Member TicketsYou may register up to 5 guests.Maternal Health - Non-Member Tickets Price: Total Please complete the information below for the Person(s) who will be attending.#1 Attendee Name(Required) First Last #1 Attendee Title(Required)#1 Attendee Email(Required) #1 Attendee Phone(Required)#1 Attendee Dietary Restrictions:(Required)#2 Attendee Name(Required) First Last #2 Attendee Title(Required)#2 Attendee Email(Required) #2 Attendee Phone(Required)#2 Attendee Dietary Restrictions:(Required)#3 Attendee Name(Required) First Last #3 Attendee Title(Required)#3 Attendee Email(Required) #3 Attendee Phone(Required)#3 Attendee Dietary Restrictions:(Required)#4 Attendee Name(Required) First Last #4 Attendee Title(Required)#4 Attendee Email(Required) #4 Attendee Phone(Required)#4 Attendee Dietary Restrictions:(Required)#5 Attendee Name(Required) First Last #5 Attendee Title(Required)#5 Attendee Email(Required) #5 Attendee Phone(Required)Other Dietary Restriction:(Required) Billing Information:The name & address listed below must match the Credit Card used.Total Coupon Name of Billing Contact (if different than the CC). First Last Email of Billing Contact(Required) Phone # of Billing Contact(Required)Billing Address(Required) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Credit Card(Required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Security Code Cardholder Name Total FACHC Events Code of Conduct Acknowledgement:(Required) By submitting this registration form, I confirm that I have read and agree to the FACHC Events Code of Conduct, which is linked below. FACHC Events Code of Conduct REFUND & CANCELLATION POLICY ACKNOWLEDGEMENT:(Required) By submitting this registration form, I acknowledge that all requests for refund must be made in writing to Nicole Rechner at nrechner@fachc.org on or before March 6, 2026. No refunds will be issued after this date. All eligible refund requests received on or before March 6, 2026, will be subject to a $50 Administrative Fee. Substitutions are welcomed and encouraged. If you have questions or need assistance registering for the 2026 Florida Maternal Health Convening, please reach out to FACHC Events & Sponsorship Manager, Nicole Rechner at nrechner@fachc.org.
