Save the Date!

Save the Date!
May 17-18, 2015
(Holiday Inn Austin Midtown)
6000 Middle Fiskville Road Austin, TX 78752
Promotores/CHW/Instructor Registration Fee: $35.00*
Includes conference materials, CEUs, and meals
*Registration fees for other participants may vary
Scholarships will be available to help cover travel/hotel costs
5 CEUs available for re-certification for
Promotores/Community Health Workers/Instructors
www.diadelamujerlatina.org - txpchw2011@gmail.com
Expanding the Role of Promotores/Community Health Workers in Promoting Prevention &
Dispelling Myths
Encuentro de Promotores: Promoviendo la Prevención y Clarificando Mitos
REGISTRATION INFORMATION/REGISTRO
Prior to
April 25
$35.00
$75.00
$10.00
Registration Fee
Promotores/Community Health Workers/Instructors*
Health Professionals, Sponsor Faculty/Staff,
Students / Trainees
After
April 25
$40.00
$75.00
$15.00
Registration fees include the following: 5 CEU credits, course syllabus/abstracts and materials, coffee
breaks, conference breakfast/snacks and social events. Registro incluye el curso de crédito continuo,
desayuno y bocaditos, cafecitos y recepción.
Cancellation Policy: Written notification of cancellation must be received prior to April 25, 2015 to
obtain a partial refund of fee (a $35.00 administrative fee is retained); thereafter no refunds will be made.
Si cancelan después del 25 de abril, se le cobra $35 para gastos administrativos.
*Scholarships: Limited quantities available for Promotores/Community Health Workers to cover hotel –
Contact Venus (Tenemos becas para el hotel – contacten a Venus)
Symposium Information Contact: Venus Ginés, txpchw2011@gmail.com
~~Maximum attendance is expected. Please register early to assure space! Registrasen pronto~~
REGISTRATION FORM –Please type or print legibly – Favor de escribir legible
Name /Nombre
Promotor (a) /Community Health Worker
Yes/Si____ No____
Instructor (a) Yes/Si___ No____
Organization/Institution/Association /Association/Organización/Asociación
Address /Dirección
City /Ciudad
State /Estado
Zip /Código Postal
Office Phone/Teléfono
Fax
E-Mail /Correo Electrónico
Specialty
Certification #
Please indicate:
 Promotor (a)/Community Health Worker
 Healthcare Administrator
 Faculty/Staff (specify)
 Health Professional (specify)
 Student/Trainee:
 Pre/Post Doc
 Other ______________________
PAYMENT INFORMATION/Pago
Haga un cheque o pague por PayPal directamente de
www.diadelamujerlatina.org
Return this form and payment payable to:
Día de la Mujer Latina, Inc.
10223 Broadway, Ste P437
Pearland, Tx 77584
________________________________________
Total Amount Enclosed: _$_________
Method of Payment (circle): Check, Purchase
Order/Requisition, or PayPal
Signature/Firma
Date/Fecha
¡Reserve la Fecha!
17—18 de mayo, 2015
Holiday Inn, Midtown, Austin, TX
6000 Middle Fiskville Road Austin, TX 78752
Cuota de Registración para Promotores: $35.00*
(Incluye materiales, CEUs, y desayuno y mucho más)
Becas disponibles para ayudar a cubrir costos de viaje/hotel
5 CEUs disponibles para re-certificación de Promotores
~Invitación y Agenda serán enviadas posteriormente~
www.diadelamujerlatina.org - txpchw2011@gmail.com
4th Expanding the Role of Promotores/Community Health Workers in Promoting
Prevention & Dispelling Myths
EXHIBITOR & SPONSORSHIP OPPORTUNITIES
REGISTRATION FORM –Please type or print legibly
Contact
Title
Organization/Institution/Association
Address
City
State
Zip
Office Phone
Fax
E-Mail
EXHIBITORS:
Include some information about what exhibitors get (ie, 1 table, 2 chairs) and any other info (limited
outlets, provide your own table cover, lunches or conference registration include for participants, max of
X# of participants, etc)
Exhibitor Type (please check):
 Corporation of more than 25 employees
 Corporation of less than 25 employees
 Hospital, Clinic, Academic Institution
 State or local government agency
 Sponsored Training Programs
 Non-profit Organization
SPONSORSHIP
Please see next page for sponsorship details and other information.
Sponsorship Levels
 Gold Contributor
 Silver Contributor
 Friend of the Mission
Prior to
April 25
$300.00
$200.00
$175.00
$75.00
$50.00
$45.00
Prior to April 25
$5000.00
$3000.00
$1000.00
PAYMENT INFORMATION
Amount Enclosed: $_____Payable to Día de la Mujer Latina, Inc.
10223 Broadway, Ste P437, Pearland, Tx 77584
Method of Payment (circle): Check, Purchase Order/Requisition, or Charge the following:
Visa, MasterCard, American Express, Discover
Card #_______________________________
Exp. Date: __________________
__________________________________________
Signature
Date
After
April 25
$350.00
$250.00
$225.00
$75.00
$75.00
$55.00
SPONSORSHIP LEVELS
Gold Contributor - $5,000
• Recognition in all advertisements and promotional materials as a Gold sponsor
• Will have the opportunity to be part of the Program’s Agenda
• Your company’s logo on all printed promotional materials (i.e. 5000 fliers along with 500
brochures).
• One (1) - 6’ x 6’ space for a stand for sampling, exhibition, or special promotion
• Special thanks and numerous mentions for recognition during the event
• Presentation for Plaque of Distinction
Silver Contributor - $3,000
• Recognition in all advertisements and promotional materials as a Silver sponsor
• Your company’s logo on all printed promotional materials (i.e. 5000 fliers along with 500
brochures).
• One (1) - 6’ x 6’ table for an exhibition, or special promotion
• Special thanks and numerous mentions for recognition during the event
Friend of the Mission (For Private Patrons- Suggested Contribution: $1000
• Your name on printed promotional materials (I.e. Event Poster and Website).
• Special thanks and numerous mentions for recognition during the event
All funds raised by “Día de la Mujer Latina” will be used by the committee to pay for all contracted
services and logistical expenses for the event on May 17-18, 2015 and no salary or honorarium will be
derived from these sponsorships. All contributions are 100% deductible
SCHOLARSHIP APPLICATION/Aplicación para la Beca
DEADLINE: May 1st 1 de mayo
A limited number of scholarships have been set aside to support hotel rooms for
Promotores/Community Health Workers who need this assistance. We also have scholarships for
gas receipts when carpooling with 4 or more. You will still need to pay for Registration.
Tenemos becas para el hospedaje si tienes necesidad y también gasolina. Favor de completar
este formulario. Usted es responsable por el pago del registro.
NOTE: if you, prefer to share the room with 3 other P/CHWs of your acquaintance, please indicate
their names below. Para las becas de hospedaje, van a tener que compartir con otros que vienen.
Si tiene los nombres de sus 3 compañeros que quieres en su cuarto, favor de añadir los nombres.
Name/Nombre
Institution/Organization/Association - Institución/Organización/Asociación
Address/Dirección
City& Zip/Ciudad / código postal
Telephone/Teléfono
Cellular/celular #
Email/correo electrónico
Sex/Genero:
□ Male/Hombre
Please check all that applies/ Marque todo que aplique:
 African American
 Alaska Native
 Caucasian
 Latino/Hispanic
 ≤ 21 yrs/años.
.
 22-63 yrs/años
□ Do you need accessible accommodations?
□ Female/Mujer
 American Indian
 Native Hawaiian
 Asian American
 Pacific Islander
 ≥ 64 yrs/años.
¿Tienes algún impedimento que deberíamos asistir para su cuarto?
Name & pone # of roommates for room. NOMBRES y # de teléfono de mis compañeros de cuarto
1.
2.
3.
□ I agree to accept this scholarship and to attend the entire event. A final evaluation form will be required.
□ Aseguro con esta firma, que voy a participar en todo el evento. Un reporte de evaluación es requerido.
Signature/Firma
Date/Fecha