COURSE REGISTRATIONSAM Working Groups • September 15-16, 2012 ...
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Preventive Care SAM Working Group - Newport Beach

Published on: Mar 4, 2016
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Transcripts - Preventive Care SAM Working Group - Newport Beach

  • 1. COURSE REGISTRATIONSAM Working Groups • September 15-16, 2012 Register online atThe Island Hotel • Newport Beach, California www.aafp.org/courses/samprepAAFP Member ID #:_ ___________________________________________ Special Needs If you have physical restrictions, please mark the appropriateName: _______________________________________________________ boxes below.Nickname (badge purposes): _____________________________________ q (952) Wheelchair Accessibility q (953) Lactation RoomDegree:______________________________________________________ q (954) Hearing Impaired Address: _____________________________________________________ q 955) Other – an AAFP staff member will contact you. (City, State, Zip: ________________________________________________ Method of Payment Enclose check or indicate credit card information for the regis-Phone: _ _____________________________________________________ tration fee. (Payment is expected to accompany this form.) q Visa q Mastercard q Discover q American ExpressFax:_________________________________________________________ q Check enclosed (payable to AAFP)E-mail (REQUIRED):____________________________________________ Total due: $_______________Emergency Contact Name:_______________________________________ Name on Card:_______________________________________________________________Emergency Contact Phone #:_____________________________________ Card Number:_ ________________________________________________________Registration On or Before After Exp Date:_ ___________________________________________________________ _ 8/13/12 8/13/12September 15 — Preventive Care (100) Signature:_ ___________________________________________________________q AAFP Member Registration Fee $165 $205q Nonmember Registration Fee $245 $305September 16 — Cerebrovascular Disease (102)q AAFP Member Registration Fee $165 $205q Nonmember Registration Fee $245 $305 GO Green! with AAFP The AAFP is focused on providing the best course resources available, while reducing environmental impact. Your registration fee includes access to course materials online, which are available approximately one week prior to the course The AAFP must receive notice of cancellation no later than start date. Additional information and instructions will be provided 21 days prior to the start of the meeting. Requests for full by email. cancellations will be refunded less a $50 administrative fee. If you wish to purchase a printed copy of the syllabus, please check See the entire policy online at www.aafp.org/cmecancellations. the hard copy syllabus box below. (You will still have access to course materials online.) Have you made your hotel reservation? Don’t forget q (101) Preventive Care Hard Copy Syllabus $10 the deadline is August 13, 2012. Hotel information is available at www.aafp.org/courses/samprep or call q (103) Cerebrovascular Diseasee Hard Copy Syllabus $10 the hotel at (888) 321-4752. Return with payment or call: American Academy of Family Physicians Attn: Contact Center 11400 Tomahawk Creek Parkway, Leawood, KS 66211 Phone: 800.274.2237 • Fax: 913.906.6075 E-mail: contactcenter@aafp.org

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