AMSSM 19TH ANNUAL MEETING REGISTRATION
Full name:
Degree:
Preferred Email Address:
Email Address to Send a Copy of the Receipt:
Full Mailing Address (Please include City, State, Zip)
Preferred Phone
Fax
Badge Information - Name on Badge:
Company/Affiliation (Please include name, address, city,
state & zip code):
Dietary or Physical Requirements:
(Please list if you have any physical or dietary requrements
which require accommodation in order to fully partiipate in this
activity.)
Please select from the societies listed below which one
you are a current member:
AMSSM Member
ACSM Member
AOSSM Member
Specialty
(Please check one box only)
Emergency Medicine
Orthopaedic Surgery
Family Medicine
Physiatry
Internal Medicine
Pediatrics
Other:
Team Physician
(Check each applicable box):
High School
Collegiate
Professional
Olympic/Elite
Other:
Registration Fee Schedule
- Please select the appropriate
category from the drop down menu below (Individuals in a
fellowship program can register at a discounted fee - a letter from
your fellowship stating you are a current fellow is required and
can be emailed to
[email protected]
NONE
Member Registration before 11/10/09 ($500)
Member Registration after 11/10/09 ($550)
Member Currently in Fellowship before 11/10/09 ($400)
Member Currently in Fellowship after 11/10/09 ($450)
Non-Member Registration before 11/10/09 ($600)
Non-Member Registration after 11/10/09
Non-Member Current Fellow before 11/10/09
Non-Member Current Fellow after 11/10/09 ($550)
How many Advance Team Physician Courses have you attended?
What years did you attend?
Payment Type:
Credit Card
Check
Please make check payable to AMSSM, to be mailed separately - Please indicate on check that payment is for membership and must include applicant’s name.
Mastercard
Visa
Discover
Name as it appears on credit card:
CVV (located on back of card)
Expiration Date: