State Coverage Initiatives National Meeting

**THIS MEETING IS FOR STATE OFFICIALS ONLY **

Registration Form

Contact Colin McGlynn at (202)292-6731, (202) 292-6831 (fax) or email colin.mcglynn@academyhealth.org with any logistical questions.

Title:	Other
First Name:
Last Name:
Job Title:
State Agency:
Department:
Address:
City:
State:
Zip Code
Telephone:
Fax:
E-Mail:

Do you have an assistant with whom we should be in contact?

Name:
Telephone:
E-mail:

Would you like to be added to our monthly Stateside eNewsletter?
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Special needs (dietary, physical, etc.):

I would like to be considered for a travel scholarship. Please include the additional scholarship request form with your registration information if you would like to be considered for a travel scholarship. This form is located on our website at statecoverage.net/travelscholarship0708.cfm

All hotel reservations must be made by calling the hotel directly at (415) 397-7000 or (800) 931-8661 by July 1, 2008. Mention this AcademyHealth RWJF/SCI meeting when making your reservation. Rooms are based upon first-come, first-served and are based upon availability.

There is no registration fee for this meeting.