amily octor - Louisiana Academy of Family Physicians

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REGISTRATION FEES (Registration fee covers CME offerings, syllabus, daily continental breakfasts and warming huts, and one ticket to the Mardi Gras party. AMOUNT TOTAL LAFP/AAFP MEMBER Member ID # $325 $ LAFP/AAFP FAMILY PRACTICE RESIDENT * Member ID # $175 $ LAFP LIFE MEMBERS Member ID # $175 $ ALLIED HEALTH/PHYSICIAN ASSISTANTS Copy of License must be attached $375 $ NON-MEMBER PHYSICIAN Please indicated specialty: $375 $ LATE REGISTRATION FEE* - If your registration is postmarked AFTER January 15, 2003, ADD $50 to your registration fee. (Family Practice Residents are exempt*) SPECIAL REGISTRATIONS & EXTRA TICKETS LIFT TICKETS (Note: Lift tickets will not be available for pickup until 6:00 am on Saturday, March 1. Tickets will not be available prior to that time.) Adult (13-64) Child (5-12) Ticket Type Quantity Quantity 1 Day $65 X $25 X $ 2 of 3 days $120 X $45 X $ 3 of 5 days $150 X $60 X $ 4 of 6 days $185 X $80 X $ 5 days $220 X $100 X $ 6 days $265 X $120 X $ Senior (Age 65-69) No group rate Senior tickets available. Add + $50 After 1/15/03 Spouse/Guest Registration (Includes daily continental breakfasts and warming huts and one ticket to the Mardi Gras party) $65 $ Mardi Gras Party (Tuesday, March 4) Adult Ticket $40 $ Mardi Gras Party (Tuesday, March 4) Child (Age 6-16) Ticket $20 $ Mardi Gras Party (Tuesday, March 4) Child (Age 5 and under) Ticket N/C # Please Indicate # EXTENDED COST Purchase directly from resort $ –NA– $ ___ I have enclosed a check payable to LAFP PAYMENT MODE LIFT TICKET TOTAL $ TOTAL AMOUNT DUE LAFP $ OR ___ I will use my credit card: ___Visa/MasterCard ___ Discover ___American Express Card Number: _________________________________________ Expiration Date: ________ Card Holder’s Name: ______________________________________ Signature: ________________________________________ NOTE: Refunds, less a $75 administrative charge, will be given on receipt of written cancellations received prior to February 1, 2003. No refunds will be given after that date. LAFP student members are invited to attend CME activities at no charge, but must pay a $25 fee to cover admittance to the Mardi Gras Party. 16
Call for Board Nominations The Nominating Committee is seeking individuals who would be willing to serve on the LAFP Board of Directors. Part of this service includes attendance at three meetings per year scheduled during the Spring (April/May), Summer (during Annual Assembly) and Fall (November). For specific position duties please contact Sonora Norman. To be considered please return the nominations form by March 1, 2003. President President-elect Vice President Secretary Speaker Vice-Speaker AAFP Delegate AAFP Alternate Delegate District 1 Directo r District 1 Alternate Director District 3A Director District 3A Alternate Director District 4 Director District 4 Alternate Director District 5 Director District 6A Alternate Director District 6B Director District 6B Alternate Director District 7 Director District 7 Alternate Director Resident Students (non-voting) LSU-NO LSU-SP Tulane Name: _________________________________________________________ Phone: ____________________________________ Fax: ___________________________________________ Email: _____________________________________________________ Address:___________________________________________________________________________________________________ 1. Please tell us why you would like to serve on the LAFP Board of Directors. __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ 2. What special skills, experiences and contributions will you bring to the LAFP as a potential Board Member __________________________________________________________________________________________________________ 7 __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ 3. What do you hope to contribute/gain from the experience __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ I understand and agree to the requirements of a Board position. Signature: _______________________________________________________ Date: _____________________________________ Clip and return by March 1, 2003, to: LAFP, 919 Tara Boulevard, Baton Rouge, LA 70806 Fax 225-923-2909. 17
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