Registration Form
IJCAHPO ' s 51 st Annual Continuing Education Program
Register online and SAVE the $ 75 processing fee : jcahpo . org / ACE
Registrations / Cancellations MUST be received on or before the following dates :
• On-Site Program Changes / Cancellations / Refunds : October 9 , 2023
• On-Demand Registration / Changes Deadline : November 16 , 2023 , 12 p . m . CT
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 __________________ |
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Number of years worked in ophthalmology EMPLOYER INFORMATION
Name of Practice
Number of years with current employer
Telephone Number
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 . � 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 .
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 .
Type or print clearly . Use one form per registrant . Duplicate this form for additional registrants .
IJCAHPO ID # Government Facility / Duty Location
What race or ethnicity do you identify most with ?
� American Indian or Alaska Native
� Asian or Asian American � Black or African American � Hispanic or Latino � Other _________________
� Native Hawaiian or Other Pacific Islander
� White or Caucasian � Prefer Not to Answer
� Multiracial / Multi-ethnic
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 .
Please indicate registration selections on reverse side .
• 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 : 651-731-0410 Questions ? 800-284-3937 . To avoid duplication , do not mail and fax registrations .
November 3 – 5 , 2023 • Hilton San Francisco Union Square 9
General Information General Information