Annual Convention Attendee Registration - Ohio Association of Health Plans

*The information collected on this form will be displayed on the event mobile app.

Name of Person Attending the Event *

Phone Number *

Email Address *

Address *

Address

City

State/Province

Zip/Postal

Organization *

Title *

Membership Type

Please Choose Your Membership Type *

Which Health Plan Member? *

Which Affiliate Member? *

Uncertain if you're a member? Click here to verify your membership.

Which Supporting Member? *

Which Supporting Premium Member? *

Health Plan Member Registration Type *

Affiliate and Affiliate Premium Registration Type *

Has Your Organization Already Registered As A Sponsor? *

Company Name Registered As Sponsor *

Additional Sponsor Opportunity Selected

Registration Type *

Table Guests

1. First Name

Last Name

Title

Email

Phone

2. First Name

Last Name

Title

Email

Phone

3. First Name

Last Name

Title

Email

Phone

4. First Name

Last Name

Title

Email

Phone

5. First Name

Last Name

Title

Email

Phone

6. First Name

Last Name

Title

Email

Phone

7. First Name

Last Name

Title

Email

Phone

Additional Registrants

Add Another? *

1. First Name *

1. Last Name *

1. Title *

1. Email Address *

Phone

Additional 1 Health Plan Amount *

Additional 1 Affiliate and Affiliate Premium Amount *

Amount *

Add Second? *

2. First Name *

2. Last Name *

2. Title *

2. Email Address *

Phone

Additional 2 Health Plan Amount *

Additional 2 Affiliate and Affiliate Premium Amount *

Amount *

Add Third? *

3. First Name *

3. Last Name *

3. Title *

3. Email Address *

Phone

Additional 3 Health Plan Amount *

Additional 3 Affiliate and Affiliate Premium Amount *

Amount *

Add Fourth? *

4. First Name *

4. Last Name *

4. Title *

4. Email Address *

Phone

Additional 4 Health Plan Amount *

Additional 4 Affiliate and Affiliate Premium Amount *

Amount *

Add Fifth? *

5. First Name *

5. Last Name *

5. Title *

5. Email Address *

Phone

Additional 5 Health Plan Amount *

Additional 5 Affiliate and Affiliate Premium Amount *

Amount *

Add Sixth? *

6. First Name *

6. Last Name *

6. Title *

6. Email Address *

Phone

Additional 6 Health Plan Amount *

Additional 6 Affiliate and Affiliate Premium Amount *

Amount *

Additional Needs

Dietary Needs: (Please note any allergies or dietary restrictions)

Pursuant to the Americans with Disabilities Act, do you require specific aids or services?

Details regarding aids or services requested

Payment

Registration Fee Amount

Payment Method *

Check (Mail to: OAHP, 20 E. Broad Street, Suite 701, Columbus, OH 43215. Your registration will not be processed until we receive payment.)

PayPal / Credit or Debit Card

All cancellations must be received in writing to the OAHP by September 1, 2023, less a $100 service charge to receive a refund and approval of cancellation. No cancellations will be accepted, or refunds issued after this date. Substitutions are accepted and encouraged.

Contract will not be processed without payment and contract authorization unless other arrangements have been made through OAHP.

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