<% if request.Form("hidIsPostback") = 1 then fname = Request.Form("fname") lname = Request.Form("lname") company = Request.Form("company") title = Request.Form("title") address = Request.Form("address") city = Request.Form("city") states = Request.Form("states") zip = Request.Form("zip") email = Request.Form("email") phone = Request.Form("phone") keynote = Request.Form("keynote") opening = Request.Form("opening") blueangels = Request.Form("blueangels") GolfOuting = request.form("GolfOuting") activeDuty = Request.Form("Active Duty") ChamberMember = request.form("Chamber_Member") ChapterMember = request.form("Chapter_Member") if chamberMember = "" then chamberMember = "No" end if if activeDuty = "" then ActiveDuty = "No" end if PayBy = request("PayBy") if ChapterMember = "Yes" then Amount = 275 elseif ChamberMember = "Yes" then Amount = 250 elseif ActiveDuty = "Yes" then Amount = 250 else Amount = 350 end if intro = "Registration - Strategic Health Intelligence Summit
" header = "" line1 = "" & fname & " " & lname & "
" line2 = "" & company & "
" line3 = "" & title & "
" line4 = "" & address & "
" line5 = "" & city & ", " & states & " " & zip & "
" line6 = "" & email & "
" line7 = "" & phone & "

" line8 = "Attending:" & keynote & "
" line9 = "" & opening & "
" line10 = "" & golfouting & "
" line11 = "" & blueangels & "

" line12 = "Active Duty:" & ActiveDuty & "
" line13 = "Chamber Member:" & ChamberMember & "
" line14 = "Chapter Member:" & ChapterMember & "
" line15 = "Paying By: " & PayBy & "
" extro = "" 'sendEmailUsingAspEmail(toEmail, toName, ccEmail, ccName, bccEmail, bccName, fromEmail, fromName, mailSubject, mailBody) subject = "Strategic Health Intelligence Registration" msg = intro & header & line1 & line2 & line3 & line4 & line5 & line6 & line7 & line8 & line9 & line10 & line11 & line12 & line13 & line14 & line15 & extro sendEmailUsingAspEmail "registrations@strategichealthintelligence.com", "Strategic Health Intelligence", "", "", "aspikes@pensacolachamber.com", "copy", email, "Online Registration", subject, msg sendEmailUsingAspEmail email, fname, "", "", "", "", "registrations@strategichealthintelligence.com", "Strategic Health Intelligence", subject, msg 'sendEmailUsingAspEmail "no.reply@weboperations.net", "Strategic Health Intelligence", "", "", "", "copy", email, "Online Registration", subject, msg if PayBy = "Credit Card" then invoiceNum = year(now()) & month(now()) & day(now()) & minute(now()) & second(now()) %> Payment in US Funds, drawn on a US bank, must accompany this for your registration to be processed.
Please press the button below to proceed to secure checkout via Authorize.net.

<% ret = InsertFP(loginid, txnkey, amount, sequence) %> ">

Credit Card Processing

 

<% else response.redirect "/summit/thank-you.asp" end if %> <% end if %> <% if request.Form("hidIsPostback") = 0 then %>

November 15th - 16th, 2011 • Pensacola, Florida

Registration Form

Price for civilian participants is $350.
Price for active duty participants is $250.
Price for Pensacola Bay Area Chamber Member is $250.
Price for HIMSS, MGMA, PAHCOM Member is $275.

---

If attending the The Center for Advancement of Health IT, Regional Extension Center-Physician Office Workshop, please call Ashley Spikes at 850-438-4081 x.230 to register and submit payment.

Summit & Physician Meaningful Use/EHR Workshop (Non-AHIT members) $425
Summit & Physician Meaningful Use /EHR Workshop (AHIT members) $375
Physician Meaningful Use/EHR Workshop (Non-AHIT members) $100
Physician Meaningful Use/EHR Workshop (Non-AHIT members) $40

HIMSS, MGMA, PAHCOM Member
Summit Only $275
Summit & Physician Meaningful Use/EHR Workshop (Non-AHIT members) $350
Summit & Physician Meaningful Use /EHR Workshop (AHIT members) $300
Physician Meaningful Use/EHR Workshop (Non-AHIT members) $100
Physician Meaningful Use/EHR Workshop (Non-AHIT members) $40

---

First Name
Last Name
Command/Company
Rank/Title
Address
City
State/Provience
Zip/Postal Code
Email
Telephone
Please select one option below for best price.
Are you Active Duty Military?	Yes
Are you a Pensacola Chamber Member?	Yes
Are you a HIMSS, PAHCOM or MGMA member?	Yes
Pay by:	Credit Card Check
Special Events:	Tuesday, November 15, 2011      5:30 p.m.      Opening Reception

Payment in US Funds, drawn on a US bank, must accompany this for your registration to be processed. For additional registrations please make a copy of this form (each registration must be filled out separately)

Person’s under the age of 18 are not permitted at the Strategic Health and Intelligence Summit. Recording Devices and cameras, still or video, are prohibited.

You may cancel you registration to the event by October 12, 2011 for a full refund. After that date, you will receive a partial refund. If you are unable to attend the event, we recommend that you send a substitution in your place.

Please fax you cancellation/ substitution to (850) 438-6369 ATTN: Armed Services or e-mail to summit@pensacolachamber.com

If you have a disability and require special attention, please call us at (850) 438-4081 Ext. 227.

For an overview of hotel information please click here.

Questions? Please Call (850) 438-4081 Ext. 227 or Ext. 230

 

<%end if%>