2012 IAFP Annual Convention - Registration Form SECTION 1 ...
2012 IAFP Annual Convention - Registration Form SECTION 1 ...
2012 IAFP Annual Convention - Registration Form SECTION 1 ...
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<strong>2012</strong> <strong>IAFP</strong> <strong>Annual</strong> <strong>Convention</strong> - <strong>Registration</strong> <strong>Form</strong>July 26-29, <strong>2012</strong> - JW Marriott, Indianapolis, INSAVE: Register before June 20. After June 20, please add $25 to all package fees.Please print. You can also register online at www.in-afp.org55 Monument Circle, Suite 400Indianapolis, IN 46204Tel: 317 237 4237Toll Free: 888 422 4237Fax: 317 237 4006iafp@in-afp.orgwww.in-afp.orgName________________________________________________________ MD_____ DO_____ Other___________Address_______________________________________City______________________ State____ Zip_________Phone____________________ Fax____________________ E-mail______________________________________Please note: confirmation message will be sent to this address<strong>SECTION</strong> 1: PACKAGES or ONE DAY ONLY CME FEES*CME Package with 2 Saturday Night Banquet TicketsIncludes: All General CME Sessions on Thu, Fri, Sat, & Sun;Electronic or Paper Syllabus; Breakfast and refreshmentbreaks on Thu, Fri, Sat & Sun; Lunch on Thu, Fri & Sat.(Package does not include Thursday SAM Study Group)Physician Membersor Ancillary Personnelemployed by <strong>IAFP</strong> Member $349Physician Non-Membersor Ancillary Personnelnot employed by <strong>IAFP</strong> Member$599*CME PackageIncludes: All General CME Sessions on Thu, Fri, Sat, & Sun;Electronic or Paper Syllabus; Breakfast and refreshmentbreaks on Thu, Fri, Sat & Sun; Lunch on Thu, Fri & Sat.(Package does not include Thursday SAM Study Group) $249 $499Single Day FeesIncludes: General CMEsessions, syllabus, meals,and refreshment breaksThursdayFridaySaturdaySundayResident or IUSM Student Members - a separate registration form with reduced fees will be mailed to you, or check our website for more detailsMC-FP SAM Study Group on Cerebrovascular Disease - Thursday, July 26Includes handout materials. The <strong>IAFP</strong> reports your answers to the ABFM.Please note: The <strong>IAFP</strong>’s SAM fee is in addition to fees charged by the ABFM. Participants in MC-FP will be required to pay MC-FP fees in orderto complete the Clinical Simulation portion of the SAM module. Participants not in MC-FP who desire to receive CME credit will be requiredto pay the current SAM fee in order to complete the Clinical Simulation portion of the SAM module and prior to receiving CME credit.SYLLABUS MATERIALS - PLEASE SELECT ONE I would like to receive my syllabus on USB drive -OR- I would like to receive my syllabus on CD-ROM -OR- I would like to receive a printed syllabus $99 $129 $99 $99 $139 $199 $139 $139$49SUBTOTAL: <strong>SECTION</strong> 1
<strong>SECTION</strong> 2: TICKETS FOR WEEKEND ACTIVITIESTickets for Saturday Banquet for adults:_____ @ $75 = $_____N.B. If you bought the banquet package in section one, your fee already includes two tickets!Tickets for Saturday Banquet for children ages 12-17:Tickets for Saturday night dinner for children ages 3-11:_____ @ $50 = $__________ @ $20 = $_____Tickets for Sunday Family Medicine Day Picnic at Victory Field _____ @ $0 = $ 0Add subtotals from sections 1 and 2.SUBTOTAL: <strong>SECTION</strong> 2GRAND TOTAL:ATTENDEE BADGE:First name/nickname preference: _____________________________________________________________PLEASE TELL US YOUR PLANNED ARRIVAL AND DEPARTURE DATES:Date of planned arrival: _______________________ Date of planned departure: _______________________PLEASE TELL US THE NAMES OF THOSE WHO WILL BE JOINING YOU AT THE CONVENTION:Spouse/Guest: _________________________________________________________________________________________Children ages 3-11: ____________________________________________________________________________________Children ages 12-17: ____________________________________________________________________________________SPECIAL NEEDS:Should you have any dietary requirements or need any special auxiliary aids in order to attend, please contact <strong>IAFP</strong> before Monday, July 16.To Register: Please complete this form & return along with your check or credit card information.Mail to: <strong>IAFP</strong>, 55 Monument Circle, Suite 400 Indianapolis, IN 46204, or FAX to: 317.237.4006.Print EXACT NAME of card holder AS IT APPEARS ON CARD: ________________________________________________Credit Card: MC VISA DISCOVER 3-DIGIT CARD SECURITY CODE: ______________Credit Card #_____________________________________________________Expiration Date_________________Billing Address_________________________________________________________________________________THIS MUST BE THE EXACT BILLING ADDRESS YOUR CARD STATEMENT IS SENT TO!City_______________________________________________ State____________ Zip_______________________Signature______________________________________________________________________________________CANCELLATIONS: Notice of cancellation must be sent in writing (by fax or mail) to the <strong>IAFP</strong> and must be received (not postmarked) byFriday, July 20, <strong>2012</strong> to be eligible for a full refund. Cancellations received after July 20 and before July 26 will be subject to a $75.00administrative fee. No shows are not eligible for a refund.
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