To register online visit: oafp.register110.com - Oklahoma Academy ...

OAFP SCIENTIFIC ASSEMBLY REGISTRATION
REGISTRATION & HOUSING
RESERVATION FORM
PERSONAL INFORMATION (Please print or type)
Last Name _____________First Name ____________Degree ____
Mailing address _________________________________________
City _________________________State ____Zip ______________
Phone _________________________________________________
Email _________________________________________________
SPOUSE/CHILDREN INFORMATION
Spouse: Last Name ______________ First Name ____________
Children (please list names and ages):
______________________________________________________
______________________________________________________
Arrival date & time: _____________________
Departure date & time: __________________
FULL FAMILY REGISTRATION $405 ___
(CME & Social Tickets)
Includes OAFP member physician, spouse and children in
the immediate family (under 16 years of age)
My spouse will participate in the guest program on:
□ Friday □ Saturday □ Both days
My children will participate in the children’s program
on: □ Friday □ Saturday □ Both days
PHYSICIAN REGISTRATION
□ Life Member Full Registration $149___
Friday CME Only $49 ___
Saturyday CME Only $49 ___
□ Active Member $295 ___
□ Thursday □ Friday □ Saturday
□ Non-Member $395 ___
□ Thursday □ Friday □ Saturday
□ New Physician Member (Discount)
(< 7yrs in practice) (-$100)
□ I have not attended Scientific Assembly
in last five years (Discount) (-$100)
□ Tulsa District Dues Paid (Discount) (-$50)
□ OKC District Dues Paid (Discount) (-$75)
□ Resident Member $0 ___
□ Thursday □ Friday □ Saturday
□ Medical Student Member $0 ___
□ Thursday □ Friday □ Saturday
□ Friday CME Only (no social tickets) $59___
□ Saturday CME Only (no social tickets) $59___
□ Two Day CME Only (no social tickets) $99___
SPONSOR A MEDICAL STUDENT $75 ___
SPOUSE/GUEST PROGRAM (Includes Social Tickets)
Full registration (both Friday and Saturday) $75 ___
One day only: □ Friday only □ Saturday only $45 ___
Spouse/guest of a resident or student FRIDAY ONLY $0 ___
CHILDREN’S PROGRAM (Includes Social Tickets)
Full registration (both Friday and Saturday) ___ x $75 ___
One day only: □ Friday only □ Saturday only ___ x $45 ___
Non-Member children (both Friday and Saturday) ___ x $130___
Children of a resident or student FRIDAY ONLY ___ x $0 ___
ADDITIONAL SOCIAL FUNCTION TICKETS
Social function tickets are included with full CME registration for
physicians and included for spouses/guests and children when
registered for the programs. Please indicate below any extra tickets
you require.
Thursday night - “Welcome Reception” ___ x $35 ___
Friday night - “Family Night at Incredible Pizza” ___ x $25 ___
Saturday night - “President’s Reception & Dinner” ___ x $65 ___
(Sorry. No children under 18 years of age. Child care
is available for those enrolled in the Children’s Program).
Sunday - “Family Fun Farewell Brunch & Bingo” ___ x $15 ___
SUNDAY, JUNE 17, 2012 SAM:GROUP LEARNING SESSION
SAM: Hypertension 6/17/12 - 8:00 am - 12:00 pm
OU-Tulsa Schusterman Center
□ OAFP Member $150 ___
□ Non-Member $375 ___
SAM: Childhood Illness 6/17/12 - 1:00 pm - 5:00 pm
OU-Tulsa Schusterman Center
□ OAFP Member $150 ___
□ Non-Member $375 ___
Email Address is required so meeting materials can be emailed to you
prior to the SAM session. The ABFM charges an additional fee starting
at $78 (the amount depends on when you recertify), to actually take the
SAM test online. You will pay this directly to the ABFM.
This Registration Form is for your planning and reimbursement purposes only.
To register online visit http://oafp.register110.com
TOTAL $ ____
HOUSING INFORMATION
The deadline for room reservations is May 1, 2012. Room request is
subject to availability. Please contact the Renaissance Hotel,
6808 S. 107th East Ave, Tulsa, OK 74133; 800-468-3571. The room
rate is $136 plus tax. Please mention that you are attending the OAFP
meeting to receive the discounted rate.
**Special Housing note to Residents!!!
Thursday night lodging will be available for Resident attendees from
Lawton or Oklahoma City who are attending the Thursday afternoon
and Friday activities. Special concessions will be made for those Residents
who wish to attend the Saturday CME. Contact the OAFP for
more information.