Registration Form 8.10.15 .pdf

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Original filename: Registration Form 8.10.15.pdf
Author: Julia Gutnik

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HealthWatch Wisconsin Presents:

The Building Blocks
of Health Coverage
An Afternoon of Medicaid and
Marketplace Workshops

Tuesday, November 3, 2015
12:30pm-4:30pm
Medical College of Wisconsin
3rd Floor, Discover Classroom
8701 W Watertown Plank Rd
Milwaukee, WI 53226
This workshop is sponsored by ABC for Health, Inc. and
HealthWatch Wisconsin. 2015-2016 HealthWatch Wisconsin
Members and Subscribers receive discounted registration!

To Register: Complete and Return this Form
This is an “intermediate” level training! Not
sure if it’s appropriate for you? Call us!

Questions? 608-261-6939 ext. 218
ABC for Health, Inc., 32 N. Bassett St., Madison, WI 53703
Phone: 608-261-6939 ~ Fax: 608-261-6938
www.abcforhealth.org
www.healthwatchwisconsin.org

Registration Form
Name:
Title/Position:
Employer:
Address:
Email:

Phone:

Current HealthWatch Wisconsin Members
Workshop Only……………………………… $20

Current HealthWatch WI members & subscribers
receive DISCOUNTED registration for this workshop.
(Current membership year runs through June 2016.)

Workshop & Membership Renewal……… $75

New to HealthWatch Wisconsin
Workshop + HealthWatch Membership….. $75
Rate includes workshop and membership for
Health-Watch Wisconsin for the 2015-2016
membership year.
Sending 3 or more? Call for group pricing.
(608)261-6939 ext. 218
Workshop Only, No Membership………… $120

Rate includes workshop and renewal of your memberRate for individuals who are not and do not wish to
ship for the 2015-2016 membership year.
become members or subscribers of HealthWatch
Sending 3 or more? Call for group pricing.
Wisconsin.
(608)261-6939 ext. 218

Payment Method:
Check (made payable to “ABC for Health, Inc.”)
Credit Card
(include CC#, expiration date, 3-digit security code, and billing address if different from above)

Require Invoice (list name and email address where to forward an invoice)

Email, Mail or Fax Your Completed Registration Form To:
ABC for Health, Inc., 32 N. Bassett St., Madison, WI 53703
Fax: (608) 261-6938 (ATTN: Matt)
Email: mkeller@safetyweb.org

Or Call to Register: (608) 261-6939 ext. 218


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