Quality Award Workshop Registration

"*" indicates required fields

Facility Name:*

Facility Name

Facility Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing/Primary Contact Name*

First Last

Billing/Primary Contact Email*

Pricing:*

$299 - Gold Workshop

$199 - Silver Workshop

$129 - Bronze Workshop

Participant Name*

First Last

Participant Email*

Would you like to register additional staff from this facility to participate in this workshop?*

Yes

First and Last Name plus Email Address for Each Additional Participant*

How Would You Like to Pay?*

Check payments must be received by WHCA/WiCAL by July 24, 2026. Otherwise, Credit Card is required.

Check

Credit Card

Total Amount Due:

Service Charge for Credit and Debit Payments:

Price: $0.00

Credit Card

Card Details

Cardholder Name

Billing Address:*

Street Address Address Line 2 City State ZIP Code