2026 Emergency Management Summit - Attendee 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 formEarly Bird Registration(Required) Early Bird Registration # of Early Bird Tickets(Required)Please enter a number from 0 to 5.Coupon Total 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 Title(Required)Attendee #1 Email(Required) Attendee #1 Phone(Required)Attendee #1 Dietary Restrictions?Attendee #1 Track Preference(Required) Peer Perspectives & Emerging Threats (Limited Seating) Integrated Response & Recovery (Limited Seating) No Preference (Wherever space is available) Tracks are subject to adjustment as final details are confirmed.Attendee 1 interested in Scholarship? Yes, I am interested in receiving a Scholarship to attend. A limited number of scholarships of up to $300 will be available to support Health Center participants attending the 2026 Emergency Management Summit. Eligibility requires full attendance and completion of all evaluation forms. Participants who do not meet these requirements will not be eligible for the scholarship. FACHC will notify selected applicants by email and confirm that scholarship funds are issued only after all requirements have been met. Scholarships will be awarded on a first‑come, first‑served basis, with a maximum of two per Health Center. Funds will be disbursed after the event once all eligibility criteria have been confirmed.Attendee # 2(Required) Salutation Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Name Last Name Attendee #2 Title(Required)Attendee #2 Email(Required) Attendee #2 Phone(Required)Attendee #2 Dietary Restrictions?Attendee #2 Track Preference(Required) Peer Perspectives & Emerging Threats (Limited Seating) Integrated Response & Recovery (Limited Seating) No Preference (Wherever space is available) Tracks are subject to adjustment as final details are confirmed.Attendee 2 interested in Scholarship? Yes, I am interested in receiving a Scholarship to attend. A limited number of scholarships of up to $300 will be available to support Health Center participants attending the 2026 Emergency Management Summit. Eligibility requires full attendance and completion of all evaluation forms. Participants who do not meet these requirements will not be eligible for the scholarship. FACHC will notify selected applicants by email and confirm that scholarship funds are issued only after all requirements have been met. Scholarships will be awarded on a first‑come, first‑served basis, with a maximum of two per Health Center. Funds will be disbursed after the event once all eligibility criteria have been confirmed.Attendee # 3(Required) Salutation Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Name Last Name Attendee #3 Title(Required)Attendee #3 Email(Required) Attendee #3 Phone(Required)Attendee #3 Dietary Restrictions?Attendee #3 Track Preference(Required) Peer Perspectives & Emerging Threats (Limited Seating) Integrated Response & Recovery (Limited Seating) No Preference (Wherever space is available) Tracks are subject to adjustment as final details are confirmed.Attendee # 4(Required) Salutation Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Name Last Name Attendee #4 Title(Required)Attendee #4 Email(Required) Attendee #4 Phone(Required)Attendee #4 Dietary Restrictions?Attendee #4 Track Preference(Required) Peer Perspectives & Emerging Threats (Limited Seating) Integrated Response & Recovery (Limited Seating) No Preference (Wherever space is available) Tracks are subject to adjustment as final details are confirmed.Attendee # 5(Required) Salutation Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Name Last Name Attendee #5 Title(Required)Attendee #5 Email(Required) Attendee #5 Phone(Required)Attendee #5 Dietary Restrictions?Attendee #5 Track Preference(Required) Peer Perspectives & Emerging Threats (Limited Seating) Integrated Response & Recovery (Limited Seating) No Preference (Wherever space is available) Tracks are subject to adjustment as final details are confirmed. 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 Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Security Code Cardholder Name Billing Address(Required) Street Address City State / Province / Region ZIP / Postal Code FACHC Events Code of Conduct Acknowledgement: 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 All requests for refund must be made in writing to Nicole Rechner at nrechner@fachc.org on or before Friday, April 10th. 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. If you have questions or need assistance registering for the Emergency Management Summit, please reach out to FACHC Events & Sponsorship Manager, Nicole Rechner at nrechner@fachc.org.
