HERO Continuing Education Conference

HERO Spring 2023 Long Term Care Continuing Education Conference
Registration Form

May 10-11, 2023
Erie Bayfront Convention Center
Facility Name*
Address*

Street Address

CityState / Province

Postal / Zip Code
Attendee 1 (Primary Contact)
Name*

Last NameFirst Name
Title/Position*
Credentials: *
Work Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Personal Email (Optional)
example@example.com
Attending: *
Add another attendee
Name*

Last NameFirst Name
Title/Position:*
Credentials: *
Work Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Personal Email (Optional)
example@example.com
Attending: *
Add another attendee
Name*

Last NameFirst Name
Title/Position
Credentials: *
Work Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Personal Email (Optional)
example@example.com
Attending: *
Add another attendee
Name*

Last NameFirst Name
Title/Position *
Credentials: *
Work Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Personal Email (Optional)
example@example.com
Attending: *
Add another attendee
Name*

Last NameFirst Name
Title/Position:*
Credentials: *
Work Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Personal Email (Optional)
example@example.com
Attending: *
Add another attendee
Name*

Last NameFirst Name
Title/Position
Credentials: *
Work Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Personal Email (Optional)
example@example.com
Attending: *
Add another attendee
Name*

Last NameFirst Name
Title/Position:*
Credentials: *
Work Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Personal Email (Optional)
example@example.com
Attending: *
Add another attendee
Name*

Last NameFirst Name
Title/Position*
Credentials: *
Work Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Personal Email (Optional)
example@example.com
Attending: *
Add another attendee
Name*

Last NameFirst Name
Title/Position:*
Credentials: *
Work Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Personal Email (Optional)
example@example.com
Attending: *
Add another attendee
Name*

Last NameFirst Name
Title/Position:*
Credentials: *
Work Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Personal Email (Optional)
example@example.com
Attending: *
Add another attendee
Name*

Last NameFirst Name
Title/Position*
Credentials: *
Work Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Personal Email (Optional)
example@example.com
Attending: *
Hotel

Each facility will be provided one (1) complimentary hotel room for one (1) night on Wednesday May 10th. Standard rooms will include two queen beds. Special requests or needs will be accommodated subject to availability. Hotel is located on convention center property. Additional room nights are $149/night plus taxes and fees.
Do you need a hotel room?*

YesNo
I only need one complimentary overnight room for the evening of May 10th reserved for
Request additional rooms to be charged to attendee.

Click here
Request for additional rooms that will be charged to the attendee:
2nd Room:
Name Reserved for and responsible for charges*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
3rd Room:
Name Reserved for and responsible for charges*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
4th Room:
Name Reserved for and responsible for charges*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
5th Room:
Name Reserved for and responsible for charges*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
If additional nights are required, please provide details (Include attendee reservation name along with Check-In Date and Check-Out Date requested in the text box):
Should be Empty:

HERO Spring 2023 Long Term Care Continuing Education Conference

Attendee 1 (Primary Contact)