AAFP Scientific Assembly 2012

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AAFP Scientific Assembly 2012

  1. 1. REGISTRATION FORM AAFP Scientific Assembly Pennsylvania Convention Center • Philadelphia, Pennsylvania Tuesday, October 16 – Saturday, October 20, 2012 Please Print the following information: AAFP ID # if applicable):____________________________________________________________ Name: __________________________________________________________________________ Nickname for badge: _ _____________________________________________________________ Degree:_________________________________________________________________________ Address: ________________________________________________________________________ City, State, Country, Zip: ____________________________________________________________ Business Phone: __________________________________________________________________ Fax:____________________________________________________________________________ E-mail (for confirmation):____________________________________________________________ Emergency Contact Name:__________________________________________________________ Emergency Contact Phone #:________________________________________________________ continued ... Part I – Registration Fee All 2012 Assembly meeting materials, badges, tickets, and promotional mailings from exhibitors will be mailed to this address. F Opt-out Options Advance Deadline September 12 Register online at www.aafp.org/assembly You can opt-out of receiving promotional mailings from exhibitors and sponsors of satellite event activities. You can also choose to not include your e-mail address in your contact information shared with exhibitors you visit. q [960] I do not wish to receive promotional postal mailings from exhibitors before and after the Assembly. q [961] I do not wish to receive promotional postal mailings from sponsors of satellite activities/events before and after the Assembly. q [962] Do not provide my e-mail address to exhibitors I visit. Scientific Assembly Fee Schedule Check appropriate box Registration category Received by September 12 After September 12 On-site fees apply q AAFP Member (Active, International, Supporting) $595 $695 q AAFP New Physician Member $520 $620 q q q q AAFP Life Member AAFP Inactive Member Resident Student $100 $100 q Allied Health Professional (RN, NP, PA, etc.) $695 $795 q Physician Nonmember $895 $995 q q Chapter Executive Chapter Staff $0 $0 Total Amount Due from Part I: $__________
  2. 2. Part II — Clinical Procedures Workshops Individual course descriptions and ticket policies can be found online at www.aafp.org/assembly. Due to the limited number of seats, please indicate your time preference for each course you would like to attend. Check appropriate box Session No.# 2011 Assembly Procedures Price Day Time Rank times by Preference q 400 Aesthetic Dermal Filler Injections for Facial Rejuvenation $240 Wed 9:00 a.m. – 12:00 p.m. 401 Wed 1:30 – 4:30 p.m. q 402 Allergy Testing and Immunotherapy $280 Fri 1:00 – 5:00 p.m. 403 Sat 8:00 a.m. – 12:00 p.m. q 404 Chemical Peels and Microdermabrasion $320 Thurs 8:00 a.m. – 12:00 p.m. 405 Thurs 1:30 – 5:30 p.m. q 406 Cosmetic Botulinum Toxin Injections (Advanced) $240 Fri 1:00 – 3:00 p.m. q 407 Cosmetic Botulinum Toxin Injections (Fundamentals) $240 Wed 9:00 – 11:00 a.m. 408 Wed 2:00 – 4:00 p.m. q 409 Cosmetic Lasers in Family Medicine (Fundamentals) $240 Thurs 8:00 – 11:00 a.m. 410 Thurs 1:00 – 4:00 p.m. q 411 Dermoscopy $210 Fri 8:00 – 11:00 a.m. 412 Fri 1:00 – 4:00 p.m. q 413 ECG Analysis (Advanced) $280 Wed 1:30 – 5:30 p.m. 414 Thurs 1:30 – 5:30 p.m. q 415 ECG Analysis (Fundamentals) $280 Wed 8:00 a.m. – 12:00 p.m. 416 Thurs 8:00 a.m. – 12:00 p.m. q 417 Electrosurgery and Cryosurgery $240 Thurs 9:00 a.m. – 12:00 p.m. 418 Thurs 1:00 – 4:00 p.m. q 419 Exercise Stress Testing (Advanced) $280 Fri 1:30 – 5:30 p.m. q 420 Exercise Stress Testing (Fundamentals) $280 Fri 8:00 a.m. – 12:00 p.m. q 421 Joint Injection $210 Wed 8:00 – 11:00 a.m. 422 Wed 1:00 – 4:00 p.m. 423 Thurs 8:00 – 11:00 a.m. 424 Thurs 1:00 – 4:00 p.m. 425 Fri 8:00 – 11:00 a.m. 426 Fri 1:00 – 4:00 p.m. 427 Sat 8:00 – 11:00 a.m. q 428 Laser/Light Therapies in Aesthetic Medicine (Advanced) $240 Fri 9:00 a.m. – 12:00 p.m. q 429 Nail Procedures $140 Fri 9:00 – 11:00 a.m. 430 Fri 2:00 – 4:00 p.m. q 431 Sideline Management Assessment Response Techniques (SMART) $280 Thurs 8:00 a.m. – 12:00 p.m. 432 Thurs 1:00 – 5:00 p.m. q 433 Soft Tissue Surgery (Advanced) $280 Wed 1:00 a.m. – 5:00 p.m. q 434 Soft Tissue Surgery (Fundamentals) $280 Wed 8:00 a.m. – 12:00 p.m. q 435 Splinting, Casting, Wrapping and Taping $280 Fri 8:00 a.m. – 12:00 p.m. 436 Fri 1:00 – 5:00 p.m. Total Amount Due from Part II: $_________ 2012 AAFP ASSEMBLY REGISTRATION FORM PAGE 2 If faxing, please include name and daytime phone number: _________________________________________________________________
  3. 3. 2012 AAFP ASSEMBLY REGISTRATION FORM PAGE 3 If faxing, please include name and daytime phone number: _________________________________________________________________ Total Amount Due from Part IV: $_________ Part IV – Assembly Celebration Friday, October 19 Spend the evening in America’s most historic square mile. Gain exclusive access to the National Constitution Center, and the Independence Visitor Center. See the President’s House, Liberty Bell, and Independence Hall. Your registration includes one ticket to the event. Additional tickets are $25 for adults and $18 for youth (ages 13-18); children twelve years of age and younger are free. Total Amount Due from Part V: $ _________ Number of tickets Session Number Ticket Type Price Total Cost (max 1) 940 Attendee Complimentary Ticket $0 $0 941 Additional Adult Ticket $25 $ 942 Additional Youth Ticket (ages 13 – 18) $18 $ 943 Additional Youth Ticket (ages 12 and under) $0 $0 Part V – AAFP Foundation VIP Benefit Friday, October 19 Join us for an unforgettable evening in the heart of America’s historic square mile. Start the night with an exclusive opportunity to see the Liberty Bell up close — and take VIP photographis with Ben Franklin and the Bell. Next, take a tour with Geroge Washington of the recently excavated open air footprint of the President’s House. Round out your VIP evening with an elaborate dinner in the Liberty View Ballroom, complete with tantalizing food and wine pairings and an extraordinary view of Independence Hall. Tickets are $250 each and include dinner and wine pair- ings with a spectacular view, VIP photos and exclusive access to iconic landmarks. Proceeds from this charitable event benefit the humanitarian, education and scientific programs of your AAFP Foundation. Session Number Type of Course Handout Total Cost q 944 Online Handouts $0 q 945 Flash Drive – $9.95 $ q 946 Printed Copy – $99.95 $ Total Amount Due from Part III: $ _________ Part III – Session Presentations Your Assembly registration fee includes online access to all session presentations. These will be available two weeks before and two weeks after Assembly. You can also purchase a flash drive containing all the presenta- tions (and additional Assembly resources) for $9.95. It will arrive prior to Assembly in your ticket and badge mailing. If you prefer hard copies, you may purchase a printed copy of all the presentations, shrink-wrapped in five individual coil-bound books, for $99.95. These are available for pick up onsite. (weighs 13 lbs.) Number of tickets Session Number Name Price Total Cost 950 AAFP Foundation VIP Benefit $250 $
  4. 4. 2012 AAFP ASSEMBLY REGISTRATION FORM PAGE 4 If faxing, please include name and daytime phone number: _________________________________________________________________ Part IX – Method of Payment To expedite registration processing, credit card payment is preferred. Please print clearly to avoid delay in processing your registration. Registration forms will be accepted only when accompanied by full payment. q MasterCard q Visa q American Express q Discover q Check Enclosed Card Number:________________________________________________________________________ Exp. Date:___________________________________________________________________________ Cardholder name:_____________________________________________________________________ Please print Signature:_ __________________________________________________________________________ Credit Card: Your signature above authorizes the AAFP to charge your credit card for the total amount above. If your registration fees are totaled incorrectly, the AAFP will make the necessary adjustments and charge your credit card accordingly. Fax to (913) 906-6075 Check: Please make payable to the American Academy of Family Physicians, drawn on a U.S. Bank in U.S. Dollars, and return to: AAFP Contact Center 11400 Tomahawk Creek Parkway Leawood, KS 66211-2680 SPECIAL ASSISTANCE Wheelchair/Scooter Rentals If you need help getting around the convention center, you may order a scooter in advance of the meeting for an additional fee. Additional Needs If you or a guest needs hearing or vision assistance in order to participate fully in Assembly activities, please let us know at least two weeks in advance. Contact us: (800) 274-2237, (913) 906-6000, or contactcenter@aafp.org. CANCELLATION POLICY: The AAFP must receive notice of cancellation by September 26, 2012. Requests for full cancellation will be refunded less a $50 administrative fee. To view the complete cancel- lation policy, please visit www.aafp.org/assembly. Part VII – Guest Registration The AAFP considers your family or significant other to be your guest (limited to four). Additional guests may be added onsite for a $25 administrative fee. Office personnel/staff must register as Allied Health Professional attendees. Guest attendees cannot attend, purchase, or report CME events/hours. Out of consideration of others, please do not bring children to CME events. 1. _________________________________________ 2._________________________________________ 3._________________________________________ 4._________________________________________ Part VIII – Total Registration Total amount due from Part I $_________________ Total amount due from Part II $_________________ Total amount due from Part III $_________________ Total amount due from Part IV $_________________ Total amount due from Part V $_________________ Total amount due from Part VI $_________________ Total amount enclosed $_________________ Part VI – AAFP Foundation Lapel Pin Get your 2012 Scientific Assembly Lapel Pin and support your AAFP Foundation! For a minimum donation, you can support important AAFP Foundation programs. This year’s pin proceeds will benefit the humanitarian efforts of your Foundation including the new program, Family Medicine Cares, which will help to establish new free clinics in areas of need. Quantity of Lapel Pins Session Number Name Price Total Cost 947 AAFP Foundation Lapel Pin $15 $ Total Amount Due from Part VI: $ _________

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