Name
Spouse's/Guest's Name
Address

At least one (1) phone number is required

Home
-
Work
-
FAX
-
Cell
-
E-mail

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CONVENTION FEES

1.     CONVENTION FEE $125 per person: Includes all lectures, Saturday banquet; breaks during the lectures; and tour of
        selected hospital sites. This DOES NOT includ:hotel room, valet parking, phone calls, etc.

2.     CONVENTION FEE FOR SPOUSE/GUEST $100 per person: Must be accompanied by someone paying the full
        convention fee (Item #1 above). This includes everything listed in Item #1 above.

3.     FEE FOR BANQUET ONLY $30 per person

We need to know if you are going to attend the Saturday tour
in order to get an accurate count for the number of busses to hire.

Saturday Tour

Total fee is Amount of Fee x Quantity

Fee $125 per person (Enter Total)
 $ 
Fee for Spouse/Guest $100.00 (Enter Total)
 $ 
Fee for Banquet Only (Enter Total)
 $ 

All convention fees include a $50.00 non-refundable booking fee.
Conference fee cannot be refunded after April 7th, 2017

NO REGISTRATIONS ACCEPTED AFTER April 7th, 2017

NO WALK-ON REGISTRATIONS ACCEPTED
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Verification: