2026 FACHC Health Center Fiscal Summit – Sponsor Registration – Florida Association of Community Health Centers

Step 1 of 3

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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)

1st Additional Attendee Name(Required)

First Last

1st Additional Attendee Title(Required)

1st Additional Attendee Email(Required)

1st Additional Attendee Phone(Required)

1st Additional Attendee Dietary Restrictions:(Required)

2nd Additional Attendee Name(Required)

First Last

2nd Additional Attendee Title(Required)

2nd Additional Attendee Email(Required)

2nd Additional Attendee Phone(Required)

2nd Additional Attendee Dietary Restrictions:(Required)

Billing Information:

The name & address listed below must match the Credit Card used.

Total

Coupon

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 Country

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 POLICY ACKNOWLEDGEMENT:(Required)

By submitting this registration form, I acknowledge that all Sponsorships are considered FINAL and no refunds will be issued.

About your Organization

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Please complete the information below for the Person(s) who will be attending.

Billing Information: