Attendee Registration Form
WAPA 2010 Spring Conference, April 14-16
Wilderness Hotel and Golf Resort – Glacier Canyon Lodge, Wisconsin Dells

Important Dates to Remember

March 14 - Hotel reservation deadline for WAPA discounted room rate.

March 26 - Registration deadline to avoid a $25 late fee. Cancellation deadline to receive refund.

Registration and Cancellation Policies

Please note registration, cancellation and late fee policies listed in the brochure. Please retain a copy of this registration form. A confirmation will be e-mailed within five business days.

Name (as you want it to appear on your name badge)
Credentials
Employer
Work Address (include city, state, and zip)
Daytime phone
E-Mail
Please indicate any special dietary needs
Please check here if you DO NOT permit WAPA to provide your contact information to exhibitors/attendees	NO

Workshop Registration
(limited to the first 20 attendees who register)

	Thursday, April 15, 8:00-10:00AM, Preceptor Training Workshop
	Thursday, April 15, 1:00-2:00PM, Joint Injection Workshop

Adjunct Meal Symposia
(Please identify all meal symposia you plan to attend)

	Wednesday, April 14, Lunch Symposium	Sponsored by GlaxoSmithKline
	Wednesday, April 14, Dinner Symposium - 5:30 PM	Sponsored by PriCara
	Thursday, April 15 Dinner Symposium - 6:30 PM	Sponsored by Merck

WAPA Fun Run/Walk
Please identify all individuals planning to participate.

Name:
Name:
Name:
Please contact Shawn Sornson if you would like to register more individuals

Registration Fees

	$300	WAPA members or other state constituent chapter members
	$425	Non-members and other health professionals (Note: $125 of this fee will cover current year membership dues)
	$0	WAPA Student member fee waived (Note: Does not include meals; students must prepurchase meals.)
	$25	Other full-time students

Daily Rates

If you are unable to attend the entire conference, you may register at the following daily rates:

	$190	WAPA members or other state constituent chapter members
	$245	Non-members and other health professionals
Check which one day you will attend:
	Wednesday, April 14
	Thursday, April 15
	Friday, April 16

Meal Tickets

If you wish to purchase meal tickets for guests, please indicate the quantity below. All meal tickets are $20.00 a piece. Students must pre-purchase meal tickets to attend meal functions.

Thursday, April 15			Friday, April 16
Continental Breakfast			Continental Breakfast
Lunch			Lunch
Total Meals:

Fee Breakdown

$		Registration Fee
$		Total Meals
$		$25 late fee if after March 26
$		Total Payment Amount

Method of Payment:

	VISA
	MasterCard
	Discover

 

Card No.	(please leave out dashes)
Exp. Date	/
Signature Code (last 3 digits on back of card)
Address on Billing Statement
Name on card

 

 

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