Greater Kansas City Medical Managers Association

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CREATING SUPER HEROES
THE POWER OF KNOWLEDGE
20th Annual GKCMMA Education Conference

Attendee Conference Registration Form
March 24, 2010

To register for the March 24, 2010 Education Conference, complete this form and be sure to click on the "Register" button when finished, even if you are paying by Check or Credit Card.

If not paying online, also fill out the "printable form" (link below) and send with your check made payable to "GKCMMA" and mail to GKCMMA Central Office, Conference Registration, P O Box 6966, Lee’s Summit, MO 64064-6966. Or fax with credit card information to (816) 554-4780 (no coversheet). If you have questions concerning your registration, please call (816) 524-6579.
** Make copies of this form for additional registrants. Please use one form per person. **

Last Name	First Name
Title/Position	Degree/ACMPE Designation
Clinic Organization
Street Address	Suite
City	State	Zip
Phone	Email
Fax	Website

I am a member of:
GKCMMA	NMM	MGMAMO	KSMGMA	Other

	$125 - GKCMMA or NMM Member Early Registration Fee, by February 26, 2010
	$150 - GKCMMA or NMM Member Registration Fee, after February 26, 2010
	$110 - Second person from a GKCMMA or NMM member practice
	$200 - Nonmember Registration
	$225 - JOINING GKCMMA MANAGER MEMBERS ONLY -- Conference and 2010 GKCMMA New Membership Combo

Payment Type:

Pay by Check or Credit Card via Fax Pay Online

If not paying online, complete this "Printable Form" and send with your check made payable to “GKCMMA” and mail to GKCMMA Central Office, Conference Registration, P O Box 6966, Lee’s Summit, MO 64064-6966. Or fax to (816) 554-4780 without coversheet. If you have questions concerning your registration, please call (816) 524-6579.

CANCELLATION POLICY
Refunds made on cancellations received or postmarked after Friday, February 26, 2010
will be subject to a $75 cancellation fee. No refunds will be made after March 19, 2010.

Hotel Reservations
For a list of area hotels near the Ritz Charles, call the GKCMMA Office at (816) 524–6579 or email info@gkcmma.com.

P.O. Box 6966 Lee's Summit, MO 64064-6966 Phone: (816) 524-6579 Fax: (816) 554-4780 info@gkcmma.com