NCHCFA 2018 ANNUAL CONVENTION AND EXPO REGISTRATION FORM - JANUARY 28-31, 2018 Return completed form to the Association office on or before Friday, January 12, 2018, by fax (919) 787-8418 or mail to 5109 Bur Oak Circle, Raleigh, NC 27612, or e-mail donnas@nchcfa.org. You can register and pay on-line. Visit http://www.nursinghomesnc.com & click on 2018 Annual Convention & Expo Registration! FACILITY/CORPORATE OFFICE ADDRESS PHONE CITY/ST/ZIP FAX CONTACT PERSON PACKAGE ONE CONVENTION & EXPO Please list first and last names as they should appear on badges. Package One does not include EXPO 2018 educational sessions (beginning at 10:30 am on Tuesday, January 30 th ). Is this your first time attending the NCHCFA Annual Convention & EXPO? If so, please let us know! Pep Rally Welcoming Reception - No Charge NCHCFA Homecoming Parade & Cookout - $45 E-MAIL Chairman s Tailgate Party & Homecoming Extravaganza - No Charge ***Please include attendee position/title: A B C D E F G H I J K L M N O 1. License # 2. License # 3. License # 4. License # Special event ticket total (Package Total) $ Advance registration received on or before January 12, 2018 Persons @ $500 Each $ This is my first time attending the NCHCFA Annual Registration received after January 12, 2018 Persons @ $535 Each $ Convention & EXPO! Please list your name below: Registration at the door Persons @ $550 Each $ Non-member registration Persons @ $1000 Each $ EXPO 2018 Luncheon - $41 Total - Package One $ Total - Package Two (from reverse side) $ Total - Package Three (from reverse side) $ Please list any special diet requirements (be very specific) for all participants registered. This will assist NCHCFA in making appropriate arrangements with the hotel: Total $ 2018 Annual Awards Gala - $65 An Update on the Enforcement Process Creating & Maintaining Advocacy Relationships Preparing for Requirements of Participation Phase 2 & the New Survey Process NCHCFA Annual Business Meeting (NCHCFA Members Only) Critical SNF Capacities for an Evolving Payment & Referral Environment The 21 st Century SNF - Innovation is the New Normal Going For It on Fourth & One! The Strategy of Leadership: Unleashing the Power of Lean Management What s New for Pharmacy Services in the Requirements of Participation Phase 2? The Nursing Staff Shortage: Exploring the Situation & Potential Solutions

PACKAGE TWO EXPO 2018 AND PACKAGE TWO SESSION (Tuesday Only) Please list first and last names as they should appear on badges. Package Two registration includes entrance into the Package Two educational session, gift bag, the EXPO 2018 luncheon, and EXPO 2018. IF A FACILITY REGISTERS TWO STAFF MEMBERS FOR PACKAGE TWO, A THIRD STAFF MEMBER (ACTIVITY DIRECTOR, DIETARY OR MAINTENANCE STAFF, NURSING ASSISTANT, OR SOCIAL WORKER) MAY ATTEND PACKAGE TWO AT NO CHARGE. Transfer all totals in section below. NCHCFA Homecoming Parade & Cookout $45 Chairman s Tailgate Party & Homecoming Extravaganza $50 2018 Annual Awards Gala - Excellence with Willie Jolley $65 Activity Director, Dietary & Maintenance Staff, Nurse, Nurse Aide, Social Worker & More Day - Finding Your Fred Factor ***Please include attendee position/title: B C E P 1. 2. 3. 4. 5. 6. Special events ticket total $ Advance registration received on or before January 12, 2018 Persons @ $145 Each $ Registration received after January 12, 2018 Persons @ $175 Each $ Registration at the door Persons @ $195 Each $ Non-member registration Persons @ $290 Each $ Total Package Two $ PACKAGE THREE SPOUSE/GUEST May not be an employee of an attending facility. Please list first and last names as they should appear on badges. Package Three registration includes entrance into the Pep Rally Welcoming Reception, Chairman s Tailgate Party & Homecoming Evening Extravaganza and EXPO 2018. Transfer all totals in section below. Pep Rally Pep Rally Welcoming Reception - No Charge NCHCFA Homecoming Parade & Cookout $45 Chairman s Tailgate Party and Homecoming Extravaganza - No Charge EXPO 2018 Luncheon $41 2018 Annual Awards Gala Celebrating Excellence with Willie Jolley $65 1. 2. A B C D E Special events ticket total $ Advance registration received on or before January 12, 2018 Persons @ $95 Each $ Registration received after January 12, 2018 Persons @ $125 Each $ Registration at the door Persons @ $135 Each $ Total Package Three $ Please list any special diet requirements (be very specific) for all participants registered. This will assist NCHCFA in making appropriate arrangements with the hotel: