2022 Collaborative Care Tech Summit - Registration

2022 Collaborative Care Tech Summit Registration Form

First Name: *

Last Name: *

Organization: *

Job Title: *

Email: *

Cell: *

Which of the following best describes your organization? *

Sharing Contact Information: *

Note: You will be redirected to a credit card/PayPal payment page. To pay with PayPal, simply login. To use a credit card, skip to select ‘Enter as guest'/pay by credit card.' Receipt will show LeadingAge as the merchant.

Select your ticket. Once you complete the registration process, you will be redirected to Authorize.net's secure payment page for fee-based tickets:

	Required Ticket* You must select one ticket from this section before continuing.	Price
	Provider Member Provider Member of one of the LTPAC Health IT Collaborative organizations	$200.00
	Provider Non Member Not a Provider Member of any of the LTPAC Health IT Collaborative organizations	$250.00
	Business Member Business Member of LeadingAge	$400.00
	Business Non Member Not a Business Member of LeadingAge	$450.00
	Speaker	$150.00

Total: 0

* required