Heart of America Eye Care Congress - Individual Registration

Note 1: If you navigate away from this page without saving, all information entered into the form may be lost.

Note 2: Unless the registration process is completed, application data is only temporarily stored and will be cleared after 30 minutes of inactivity.

Type:
Virtual:	Yes No In-Person registration is limited. (175/350)
Prefix:
First Name:
Last Name:
First or Nickname for Badge:
ARBO OE Number:	Can't remember? Click here to look it up.
Practice:
Title:
	I am an AOA Member (American Optometric Association). Yes No I desire ABO (American Board of Opticianry) certification?: Yes No Paras Only To receive ABO certificates you must register by Jan. 15. ABO Certificate Fee: $50.00

	I require CEE(TQ) for my state license renewal?: Yes No I have an Illinois state license: Yes No I have a Florida state license. Yes No
State License Number:

Address:
Address2:
City:
State:
Zip:
Phone:
Mobile:
	Please check this box if you would like to receive text notifications during the Eye Care Congress, including last-minute schedule changes, event updates and more. The Heart will only send texts during the Congress and will not share this information with any 3rd party. Yes No
Fax:
Email:	(All registration emails for this individual will be sent to this address.)
Confirm Email:
	Do you give the Heart permission to share your email address with Heart Exhibitors and Sponsors to be used strictly for the 2021 HOAECC Congress? Yes No
	Policy for Use of Imagery and Other Digital Media
Where did you hear about HOAECC?
Other:
How many years have you attended the Congress (including 2021 HOAECC)?

School:
Graduation Year:

Notice: You have 30:00 minutes left in your session. This means that any data entered into this form and not saved by moving on to another step in the process will be lost. So, please, save your work.

Registrant Information

Guest Information

February 12-14, 2021 Westin Crown Center Kansas City, Missouri

Notice: You have 30:00 minutes left in your session. This means that any data entered into this form and not saved by moving on to another step in the process will be lost. So, please, save your work.

Registrant Information

Guest Information

February 12-14, 2021
Westin Crown Center
Kansas City, Missouri