Registration Form
October 9 – 11, 2026 | Hilton New Orleans Riverside- Page 9
IJCAHPO ' s 54 th Annual Continuing Education Program
Register online and SAVE the $ 75 processing fee: jcahpo. org / ACE
IJCAHPO ID # Government Facility / Duty Location
Registrations / Cancellations MUST be received on or before these dates:
• On-Site Program Changes / Cancellations / Refunds: September 23, 2026, 11:59 p. m. CT
• On-Demand Registration Deadline: October 22, 2026, 12:00 p. m. CT
Type or print clearly. Use one form per registrant. Duplicate this form for additional registrants.
REGISTRATION INFORMATION REGISTRANT INFORMATION
Please list your credentials Date of Birth( mm / dd / yy) / /
Name � Ms. � Mrs. � Mr.()
First M. I. Last Former Name, if Applicable Home Address City State / Province Zip Country
Preferred Telephone-- Preferred Email Address
IN CASE OF EMERGENCY, PLEASE NOTIFY-- Name
Which category best describes your professional activities?( Check all that apply) |
� Administration / Management � Contact Lenses |
� Nursing |
� Scribe |
� Clinical Research |
� Front Office |
� Ophthalmic Photography � Student |
� Clinical / Diagnostic Testing |
� Laser Technology |
� Optical |
� Surgical Assisting |
� Coding Specialist |
� Low Vision |
� Orthoptics |
� Surgical Coordinator |
� Other __________________ |
|
|
|
Number of years worked in ophthalmology EMPLOYER INFORMATION EMPLOYER INFORMATION
Name of Practice
Number of years with current employer
Telephone Number What race or ethnicity do you identify most with?
� American Indian or � Native Hawaiian or Alaska Native
Other Pacific Islander � Asian or Asian American � White or Caucasian � Black or African American � Prefer Not to Answer � Hispanic or Latino � Multiracial / � Other _________________ Multiethnic
Business Address City State / Province Zip Country
Business Telephone-- Ext. Fax Number--
Employer’ s Practice Emphasis( Check all that apply) |
� Cataract / IOL |
� Glaucoma |
� Ophthalmic Pathology |
� Refractive Surgery |
� Comprehensive Ophthalmology |
� Low Vision |
� Optical Dispensing |
� Retina / Vitreous Disease |
� Contact Lens |
� Neuro-Ophthalmology |
� Pediatric Ophthalmology / Strabismus |
� Other ___________________________ |
� Cornea / External Disease |
� Oculoplastic / Reconstructive Surgery |
|
METHOD OF PAYMENT Registrations received without payment will NOT be processed
METHOD OF PAYMENT Registrations received without payment will NOT be processed.
|
� Check � Money Order � VISA � MasterCard � Discover � American Express
If paying by check or money order, please make payable to IJCAHPO. Checks must be in U. S. dollars( USD). If paying with a credit card, please complete the information below. A $ 75 NSF fee will be assessed for declined checks and declined credit cards.
IJCAHPO reserves the right to adjust registration charges originally paid with a credit card via fax, mail or internet if the amount originally paid was deficient or excessive. The credit card account will be charged or credited and the cardholder will be provided with a notice of the adjustment.
Card # Expiration Date / Security Code
Payer’ s Name( Please PRINT)
Payer’ s Billing Address City State / Province Zip Country
Authorized Signature X
Check Preferred Address � Home � Work
Special accommodations: IJCAHPO provides reasonable and appropriate accommodations on-site at the program venue to individuals with documented disabilities who demonstrate a need for special accommodations. Specific special accommodations should be related to functional limitations. Please include additional supporting documentation from the medical professional who diagnosed the condition. It is essential that the documentation of the disability provides a clear explanation of the current functional limitation( s) and a rationale for the requested accommodation. For more information contact IJCAHPO at 800-284-3937.
Please indicate registration selections on page 10.
• Register online at jcahpo. org / ACE and click on REGISTER
• Send registration form with payment to: IJCAHPO, 2025 Woodlane Drive, St. Paul, MN 55125-2998
• Fax: 651-683-5005 Phone: 651-731-2944
Questions? 800-284-3937. To avoid duplication, do not mail and fax registrations.