Conference Registration

Name(Required)

First Last

Email(Required)

Phone

Hospital Affiliation(Required)

Registration Fee by Membership Level(Required)

Emeritus Member - $0

Active Member - $150

Associate Member - $150

Candidate Member - $150

Fellow/Resident/Student Attendee - $0

NP/PA/RN Non-member Attendee- $50

Physician Non-member Attendee- $150

Additional fees will be incurred for late registration and weekend-of registration.

(Cocktail Party with Hors d’oeuvres - Admission: $0)

Adults Attending Cocktail Party

Please enter a number from 0 to 99.

# of Adults (18 and above)

Children Attending Cocktail Party

Please enter a number from 0 to 99.

# of Children (17 and under)

List names of attendees below

(Cocktail Reception and Dinner)

Adults - Cocktail Reception & Dinner

(18 years old & over) in attendance

Price: $75.00

Kids & Teens - Cocktail Reception & Dinner

(7 - 17 years old) in attendance

Price: $25.00

Small Kids - Cocktail Reception & Dinner

(6 years old & under) in attendance

Price: $0.00

List names of attendees below

Total

68306