April 16-17, 2009

MEETING REGISTRATION FORM

Yes, I plan to attend the Alcalde Conference. Please check appropriate day(s).

_____ Thursday, April 16        _____ Friday, April 17       

Name ______________________________________________________________

Residency Facility_____________________________________________________

Work Address ________________________________________________________

City State Zip ________________________________________________________

Work Phone ________________               Home Phone _______________________

E-mail ____________________________________
 

Indicate any special dietary/ADA needs:____________________________________

____ Resident/Fellow ($150; $175 after 3/31/09)

____ Student ($25; $40 after 3/31/09)

____ Resident/Fellow-Alcalde and Full TSHP Seminar ($260; $320 after 3/31/09)*

____ Resident/Fellow-Alcalde and 2 day Seminar ($225; $285 after 3/31/09)*

____ Resident/Fellow-Alcalde and 1 day seminar ($200; $260 after 3/31/09)*

____ Preceptor (Pharmacist) or Guest - Alcalde Only ($150; $175 after 3/31/09)

____ Preceptor-Alcalde and Full TSHP Seminar ($380; $450 after 3/31/09)**

____ Preceptor-Alcalde and 2 day Seminar ($320; $380 after 3/31/09)**

____ Preceptor-Alcalde and 1 day Seminar ($250; $300 after 3/31/09)**

* TSHP Non-members, add $62.50, which includes 2009-10 membership.

** TSHP Non-members, add $125, which includes 2009-10 membership.

Charge my q MasterCard     q Visa     q American Express      q Discover

Card # ______________________________    Exp. Date: _________________

Name on card: ____________________________________________________

Signature: _______________________________________________________

Please make checks payable to Alcalde-Southwest Leadership Conference.

Please mail form to:

Alcalde- c/o TSHP R&E Foundation
3000 Joe DiMaggio #30-A
Round Rock, TX 78665-3994
1-800-242-TSHP (8747) Fax: 512-852-8514        E-Mail: foundation@tshp.org

EIN 75-1578067