This form is for healthcare provider organizations to request participation in the HIMSS AZ–WA Chapter Golf Invitational at Ocotillo Golf Club. Provider participation is prioritized and offered at no cost. Submissions will be reviewed and confirmed prior to final acceptance.

Provider Registration Form

First Name *

Last Name *

Organization / Health System *

Job Title *

Phone *

Mobile Phone Preferred

Email *

Business Email Preferred

Provider Eligibility

Provider Organization Type *

Hospital

Health System

Payer

Provider-Affiliated Organization

Are you directly affiliated with a provider organization? *

Yes

No

Golf Participation

Handicap (optional)

Shirt Size (optional, but helpful for swag)

Small

Medium

Large

Extra Large

2XL

3XL

Confirmation

I understand that provider registrations will be reviewed and confirmed prior to final acceptance.

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