Community Health Care Association
of New York State

Community Health Center Advocacy Day Registration Form

Date: February 1, 2010
Location: New York State Empire State Plaza Convention Center, Albany, NY


Thank you for registering!

Please fill out and submit this form to complete your registration. If you have questions or need additional information, please contact us at grassroots@chcanys.org. or call (518) 434-0767 x12. Thank you.

Fee: Complimentary

Please contact your Health Center for transportation arrangements. Car pools, buses and vans are recommended.

First Name* : 
Last Name* : 
Title : 
Center/Organization* : 
Business Zip Code : 
Home Zip Code : 
Email* : 

*After 5 pm on Thursday January 28th, we cannot guarantee the availability of a wheelchair or a meal. There is food available for purchase nearby within the Empire State Plaza.


I am a : 

Are you a member of the Grassroot Action Network?

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Please complete the below information if you are completing this form for someone else.
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Community Health Care Association of New York State (CHCANYS)
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