Innovation Workshop Registration

Please complete a separate form for each attendee.

Your registration is not confirmed until payment is received. Confirmation will be sent via email along with pre-workshop preparation material.

1. Contact Information

Person's Name:	E-mail Address: (i.e., john.doe@kp.org)
Phone Number: (i.e.,925.555.4481)	Cellular Phone Number: (i.e.,925.555.4481)
Organization Name:	Job Title:
Street Address:	City, State, Zip or Postal Code, Country

2. Additional Information

Dietary Restrictions?: (i.e., vegetarian, food allergies)
How did you learn about this workshop:
If you will attend a post workshop session, choose one: Session #7 - Build Your Own Innovation Center OR Session #8 - Tour the Garfield Center
Workshop Registration Fee: $250.00 U.S.	Make checks payable to: Kaiser Foundation Health Plan, Inc 590 Whitney Street San Leandro, CA 94577