Please complete the registration below. Registrant Information First Name Last Name Title Credentials At which office or care site are you based? Good Samaritan Medical Center Holy Rosary Healthcare Lutheran Medical Center Medical Group Platte Valley Medical Center Saint Joseph Hospital St. James Healthcare St. Mary's Medical Center St. Vincent Healthcare System Other If other, please specify. Office City Office State CO KS MT Phone Email Assistant Name Assistant Phone Assistant Email Will you be attending the dinner at the Denver Marriott Westminster? Yes No Meal Choice Beef Chicken Vegetarian Please describe any dietary restrictions. If none, leave blank. Please choose a promotional item. Men's Vest Women's Vest Blanket If Men's vest chosen, please select a size S M L XL If Women's vest chosen, please select a size S M L XL Have you attended an SCL Health leadership assembly in the past? Yes No (Hotel reservation information will be included in your registration confirmation.) Have you made a reservation at Denver Marriott Westminster? Yes, I have registered No, I have not yet registered N/A - I won't need a hotel room Which nights are you planning on staying at the hotel? Sunday, September 8 Monday, September 9 Tuesday, September 10 Wednesday, September 11
