Online Registration

Registration closes Thursday, October 29, 2009. HBS Health reserves the right to close registration before this deadline if the event sells out. There will be no on-site registration.

Fields in red required to submit form.

First Name:

Last Name:

Nametag Name:

Company:

Title:

Street:

City:

State:

Zip:

Country:

Phone:

Fax:

E-mail:

HBS Degree/
Program:

AMP		PMD
MBA		PHSM
OPM		TGMP
MOC		Not applicable

Function:

Other:

Sector:

Other:

HBS HIAA Member:

Yes
No
If no, are you affiliated with:
HMS
HSPH
HKSG

Cancellation and Refund Policy:

All cancellations must be received in writing. If received by October 1, 2009, a full refund will be issued. Cancel between October 2 and 13, 2009, and you will receive a 50% refund. No refunds will be issued after October 13, 2009. However, registration can be transferred to another HBS alumnus not registered for the conference.

Conference Fees:
HBS HIAA Members:		$775
HBS HIAA Benefactors:		$545
HBS HIAA Patrons:		$675
Non-members:		$1,025
Special Rates:
Speaker:		$0
Sponsor:		$0
Board Member:		$0
Roundtable Leaders:		$350
HBS Faculty/Students:		$185
Spouse/Guest:		$265 (No access to sessions; meals only.)
Guest Name:
Final Conference Event: "Harvard Innovations" Saturday, November 7, 1:30 p.m. - 3:30 p.m.
		Yes (price included in conference fee for conference attendees)
		No
Total:
I will attend:		Reception (Thursday evening, Nov. 5th)
		Ellerin Award Dinner (Friday evening, Nov. 6th)
		Lunch (Saturday, Nov. 7th)

Credit Card Information:
Credit Card:		American Express
		MasterCard
		Visa
Credit Card Number:
Exp. Date:		(mm/yy)
Name (as on card):