Hospital Security Forum Application

Application to Attend

January 13-15, 2025, Renaissance Waverly Hotel, Atlanta, GA
For assistance, please call 973-514-5900 ext. 108

This form is for hospital security directors. For Vendor info, call 973-514-5900 ext. 111
Name*

First NameLast Name
Title*
Hospital/Organization Name*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Cell Number*
Please enter a valid phone number.
Emergency Contact*
Please include name and Phone Number
Nickname for badge (optional)
Eg. Bob for Robert
Tell us about your organization
How many beds does your hospital have?*
If you run a multi-site system, how many total beds are in the system?*
How many hospital EMPLOYEES are in your security department?*
How many CONTRACTOR positions (FTE) does your security dept. use?*
Tell us about what you source
Visitor Management*
Metal/Weapon Detection*
Access Control Systems and Hardware*
Camera and Video Management Systems*
Third-Party Guard Services*
Parking Management*
Staff Panic Buttons*
Infant Protection*
Anything else you're looking to source for your hospital?*
What issues would you like to discuss at the forum?*
Name AND Title of your immediate supervisor. *

Application Fee*

Application Fee - Hospital Security Forum$199 fee INCLUDES two nights Hotel, Meals, and Event Fees. Airfare reimbursed onsite (up to $599) if you request (see below). Up to 60 days prior to the event, you may receive a refund less a $50 processing fee. After that no refunds will be issued.

$199.00

Enter coupon

Total

$0.00

Credit Card

Upon your approval to attend, we ask that you purchase and submit your paid airline itinerary within 15 days and send a copy to mike@eatonhall.com.
Reimbursement*

I would like airfare reimbursementI will pay my own airfare
Airfare Reimbursement should be made Payable To:
You agree to attend all sessions and abide by the rules of the forum.*

Yes, I agree
Please verify that you are human*
Should be Empty:

Application to Attend

Tell us about your organization

Tell us about what you source

Credit Card