12th ANNUAL FOCUS ON RESPIRATORY CARE & SLEEP MEDICINE CONFERENCE (Focus Spring) THE GAYLORD OPRYLAND HOTEL - NASHVILLE, TN • MAY 10-12, 2012


PLEASE PRINT CLEARLY - REGISTRATION FORM - PLEASE PRINT CLEARLY


THIS REGISTRATION FORM IS FOR MAILING ONLY - FAXED REGISTRATIONS WILL NOT BE ACCEPTED REGISTRATION IS ALSO AVAILABLE ONLINE AT WWW.FOOCUS.COM


Name_______________________________________________________ Primary Credential__________________________________ Job Title ____ Department Director


____ Assistant Director, Supervisor or Clinical Coordinator


___Respiratory ___Sleep ___ Respiratory & Sleep ___Respiratory ___Sleep ___ Respiratory & Sleep


____ Homecare Manager ____ Homecare Staff Therapist ____ School Program Director ____ School Faculty Member ___ Respiratory ___Sleep ___ Respiratory & Sleep ____ Sleep Lab Staff Technologist ____ Hospital Staff Respiratory Therapist ____ Registered Nurse ____ Registered Nurse Manager


Employer________________________________________________________City_______________________________State________ Home Address___________________________________________________________________________________________________ City_________________________________________________________________State_______________Zip_____________________ Work Ph ( __________ )____________________________________Home Ph ( __________ )__________________________________


E-mail Address to which confirmation will be sent _____________________________________________________________ (Required, as confirmations will be sent only by e-mail)


REGISTRATION FEES: ____ Full 3 day registration ____ Full 3 day registration


(May 1 or before)


____ Two day registration - choose ____ 5/10 & 5/11 (TF) OR ____ 5/11 & 5/12 (FS) (May 1 or before) ____ Two day registration - choose ____ 5/10 & 5/11 (TF) OR ____ 5/11 & 5/12 (FS) ____ One day registration - choose one ____ 5/10 (T) ____ 5/11 (F) ____ 5/12 (S) ____ One day registration - choose one ____ 5/10 (T) ____ 5/11 (F) ____ 5/12 (S)


STUDENT REGISTRATION - Includes all lectures and events ____ Full 3 day registration


____ Full 3 day registration $350 (FCB)


(After May 1 or on-site) $450 (FCA) $300 (TDB)


(After May 1 or on-site) $400 (TDA) (May 1 or before)


$225 (ODB) (After May 1 or on-site) $275 (ODA) (May 1 or before) ____ Two day registration - choose ____ 5/10 & 5/11 (TF) OR ____ 5/11 & 5/12 (FS) (May 1 or before) (May 1 or before) $100 (SDFCB)


(After May 1 or on-site) $195 (SDFCA) $75 (SDTDB)


____ Two day registration - choose ____ 5/10 & 5/11 (TF) OR ____ 5/11 & 5/12 (FS) (After May 1 or on-site) $150 (SDTDA) ____ One day registration - choose one ____ 5/10 (T) ____ 5/11 (F) ____ 5/12 (S) ____ One day registration - choose one ____ 5/10 (T) ____ 5/11 (F) ____ 5/12 (S)


$50 (SDODB) (After May 1 or on-site) $100 (SDODA)


The signature of my Program Director (required) follows. School ________________________________________ Program Dir. Signature______________________________________ DISCOUNT: ____ I am eligible for a $25 discount because I attended a previous FOCUS Conference, attending last in _________.


(Year) “SIGNIFICANT OTHER” REGISTRATION - Includes all activities and events. (No CEUs in this category.) (FREE) (SO) Printed Name of Significant Other ________________________________________________________________________________


NEW AT FOCUS 2012 - BRING A COLLEAGUE AND HAVE FIVE CHANCES TO WIN A NEW KINDLE FIRE !!!! Yes, enter me into the drawing to win one of five Kindle Fires that will be given away at the FOCUS conference. I am personally responsible for my colleague_______________________________________________ registering as a


paid attendee to the conference. I certify that he/she has never attended before. (Print colleague’s name above)


POLICY ON CHILDREN: Children under the age of 18 are not allowed into any of the conference’s functions. The exception is the Grand Ole Opry show where all family members of registered attendees are welcome. A registered attendee may have one person 18 years of age or older attend the conference and all of it’s functions if that person is registered as that attendee’s one significant-other.


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