Pediatric Fundamental Critical Care Support. Disney's Yacht and Beach Club
Resorts, Lake Buena Vista, Florida, USA | July 23-24, 2014. Payment Information:
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Registration Form Fundamentals of Critical Care Ultrasound | Sheraton Puerto Rico Hotel and Casino, San Juan, Puerto Rico | January 18-19, 2013
Pediatric Fundamental Critical Care Support Registration Form
Fundamentals of Critical Care Ultrasound | Sheraton Puerto Rico Hotel and Casino, San Juan, Puerto Rico | January 18-19, 2013 ChooseDisney’s from fourYacht easy ways register: andtoBeach Club
Resorts, Lake Buena Vista, Florida, USA | July 23-24, 2014
For orders placed online or by phone, please have your credit card and customer ID ready.
1. Online: www.sccm.org/ultrasound 2. Phone: +1 847 827-6888 3. Fax: +1 847 493-6444 4. Mail: SCCM, 35083 Eagle Way, Chicago, IL 60678-1350, USA 1. Online: www.sccm.org/PFCCSCourse Choose from four ways to register: Choose from four easy ways to easy register: 2. Phone: +1 847 827-6888 orders placed online oryour by phone, please Please type orplaced print For clearly. Please keep a copy of this forcredit your card records. For orders online or by phone, please haveform and customer ID ready. 3. Fax: +1 847 493-6444 have your credit card and customer ID ready. 1. Online:ID#:___________________________ www.sccm.org/ultrasound 2. Phone: +1 847 827-6888 3. Fax: 847 SCCM, 493-644435083 4. Mail: SCCM, 35083 Eagle Way, Chicago, IL 60678-1350, USA 4.+1 Mail: Eagle Way, Chicago, IL 60678-1350, USA Customer First Name: ___________________________ Middle Initial: _____ Last Name/Surname: __________________________________ Organization: Please type or print__________________________________________________ clearly. Please keep a copy of this form for your records.
Male
Female
Address: ___________________________________________________________
City: ________________________________________________________ State/Province: ______________ Zip/Postal Code: _________________________ Customer ID#:___________________________ First Name: ___________________________ Middle Initial: _____ Last Name/Surname: __________________________________ Home Office Country: ________________________________________________ Address Type:
Male
Female
Organization: __________________________________________________ Address: ___________________________________________________________ Phone: _____________________________________ Fax: ____________________________________ Email: _______________________________________ City: ________________________________________________________ State/Province: ______________ Zip/Postal Code: _________________________ Please list all of your Degrees/Credentials (ex.: ACNP, MD, PharmD, RN, RRT, etc.): ___________________________________________________________ Home Office Country: ________________________________________________ Address Please list your Primary License/Board Certification (ex.: Registered Nurse,Type: Internal Medicine): ________________________________________________ Phone: _____________________________________ Email: _______________________________________ Please list your Primary License/Board CertificationFax: year____________________________________ (ex.: 2001): ______________________________________________________________________ Please list all of your Degrees/Credentials (ex.: ACNP, MD, PharmD, RN, RRT, etc.): ___________________________________________________________
CourselistRegistration Fees ( Please your Primary License/Board Certification (ex.: Registered Nurse, Internal Medicine): ________________________________________________ Conference
Early Rate
Advance Rate
On-Site Rate
$1590 $1075
$1790 $1275
$1940 $1425
Early Rate
Advance Rate
On-Site Rate
Amount Due
Please list your Primary License/Board Certification year (ex.: 2001): ______________________________________________________________________ November 14, 2012 December 12, 2012 Fundamentals of Critical Care Ultrasound 2 Days: January 18-19, 2013
Course Registration ( Course Fees Registration NEW: Select your skill station: Conference Adult Pediatric (limited availability)
SCCM Members Physician Fees Healthcare Professional*
Please note: You will be assigned to either the adult Fundamentals of Critical Care or pediatric skill station track for bothUltrasound days. In order SCCM to Days: keep our small faculty/learner ratios,Members we will not 2 January 18-19, 2013 be able to make any changes to these assignments.
NEW: Select your skill station: Adult Pediatric (limitedNonmembers availability)
Amount Due Nonmembers Rate 14, 2012 December 12, 2012 November Physician $1795 $1995 $2145 SCCM Members Physician ............................................. $440 Healthcare Professional* $1280 $1480 $1630 Physician $1590 $1790 $1940 Healthcare Professional* ..................... $265 Healthcare Professional* $1075 $1275 $1425 Physician ............................................. $525 Nonmembers Healthcare Professional* ..................... $330
Amount Due
$
$
$
Please note: You will be assigned to either the adult Physician $1795 $1995 $2145 or pediatric skill station track for both days. In order $ Healthcare Professional* $1280 $1480 $1630 to keep our small ratios, we will not *Verifi cation letterfaculty/learner required with registration forwith fellows, residentsforand students to receive Healthcare Professional rate. *Verification letter required registration fellows, residents andthe students to receive the Healthcare Professional rate. be able to make any changes to these assignments. Advance registration will be accepted until December 12, 2012. Thereafter, registrations will be accepted on site only.
Payment Information: Please send payment with registration form. Inquiries can be emailed to
[email protected].
$
Payment Information: Please send payment with registration form. Inquiries can be emailed to
[email protected].
*Verification letter required with registration for fellows, residents and students to receive the Healthcare Professional rate. Check (must be U.S. funds drawn on a U.S. bank) Credit Card: American Express Discover MasterCard Advance registration will be accepted until December 12, 2012. Thereafter, registrations will be accepted on site only.
Visa
Card Number: _______________________________________________________________________________ Expiration Date: ______________________ Cardholder Name: __________________________________________________________________________________________________________________ Payment Information: Please send payment with registration form. Inquiries can be emailed to
[email protected]. Cardholder Signature: ________________________________ Check (must be U.S._______________________________________________________________________ funds drawn on a U.S. bank) Credit Card: American Express Discover Date:MasterCard Visa Card _______________________________________________________________________________ Expiration Date: ______________________ If you Number: have special needs related to a disability, please contact SCCM Customer Service at +1 847 827-6888 or via email at
[email protected]. Cardholder Name: __________________________________________________________________________________________________________________ Cancellations must be submitted in writing. All cancellations are subject to a $75 non-refundable processing fee and must be postmarked prior to December 12, 2012, Cancellations must be submitted in writing. All cancellations are subject to a $75 non-refundable processing fee and must be postmarked prior to July 2, 2014, to be eligible for a to be eligible for a refund. Cancellations postmarked after this date will not be refunded. Dates for the Fundamentals of Critical Care Ultrasound course are subject to change and/or refund. Cancellations postmarked after this date will not be refunded. Dates for the Pediatric Fundamental Critical Care SupportDate: course________________________________ are subject to change and/or cancellation. Cardholder cancellation. InSignature: the event of _______________________________________________________________________ cancellation only individual registration fees will be reimbursed. Please allow four weeks to process refunds. In the event of cancellation only individual registration fees will be reimbursed. Please allow four weeks to process refunds. If you have special needs related to a disability, please contact SCCM Customer Service at +1 847 827-6888 or via email at
[email protected]. Cancellations must be submitted in writing. All cancellations are subject to a $75 non-refundable processing fee and must be postmarked prior to December 12, 2012, to be eligible for a refund. Cancellations postmarked after this date will not be refunded. Dates for the Fundamentals of Critical Care Ultrasound course are subject to change and/or cancellation. In the event of cancellation only individual registration fees will be reimbursed. Please allow four weeks to process refunds.
