Registration Form AMGA’s 2018 Institute for Quality Leadership November 13–15, 2018 • Hyatt Regency San Antonio Riverwalk • San Antonio, Texas
Please print or type all information. One individual per form please. This form may be photocopied for additional registrants.
Registrant’s Full Name and Degree (if applicable)_____________________________________________________________________________________________
Job Title ______________________________________________________________________________________________________________________________
Organization Name _____________________________________________________________________________________________________________________
Mailing Address _______________________________________________ City _______________________State _______ZIP _______________________________
Telephone____________________________________________________ Email ___________________________________________________________________
Assistant’s Name & Email ________________________________________________________________________________________________________________
First Name/Nickname (to appear on badge)_________________________________________________________________________________________________
Emergency Contact Name and Telephone __________________________________________________________________________________________________
National Provider Identifier (NPI) Number (if applicable) _______________________________________________________________________________________
IQL (November 14-15, 2018) By September 28 September 29-October 26 After October 26
Includes IQL General Sessions, Peer-to-Peer Breakouts,
and meal functions with exhibitors.
AMGA Member or Corporate Partner o 825 o 925 o 1,025
AMGA Non-Member or Non-Corporate Partner o 1,650 o 1,850 o 2,050
Leadership Councils (November 13, 2018)
Participation in the AMGA Leadership Councils is
limited to the members of the Councils only. If you are unsure
of your status, please contact Joe DeLisle at firstname.lastname@example.org
or 703.838.0033 ext. 355.
Leadership Council Meeting o 275 o 275 o 275
Please select which council you are attending:
o CAO/COO o CEO/President/Chair o CMO/Medical Directors o CNO o CQO/Director
Spouse/Guest of IQL
This fee covers the Welcome Reception on Tuesday, November 13, as well as breakfasts,
lunches, and receptions in the Exhibit Hall November 14-15. Spouse/Guest Fee o 175
Spouse/Guest of Leadership Council Reception
This fee covers the Council welcome event on Monday, November 12. Spouse/Guest Fee o 50
Name of Spouse/Guest ____________________________________________________________________
Spouse’s/Guest’s First Name/Nickname (to appear on badge)____________________________________
Cancellations must be submitted in writing by Friday, October 5 in order to receive a refund, less a $100 cancellation fee.
After this date, cancellations will receive a Letter of Credit for the amount paid, less a $100 cancellation fee.
o Check, in the amount of _____________, is enclosed.
o Please charge _____________ to my o Visa o MasterCard o American Express
Card number Expiration date Security Code
Name (please print) Signature
Questions? Contact Bruce Hadloc at email@example.com or 703.838.0033, ext. 366.
For more information, visit amga.org/IQL18
Total Amount Due: