EMCON 2008 Registration Form:Emergency Medicine Department:SUNY Upstate Medical University

EMCON 2008 Registration Form

Cancellation Policy

Cancellation must be confirmed in writing by October 15, 2008 to qualify for a refund. Written notice of cancellation must be received by SUNY Upstate Medical University, Department of Emergency Medicine, EMSTAT Center postmarked no later than October 15, 2008. No refunds will be issued after this date.

If you prefer to register by mail or fax, you must use our EMCON 2008 Registration Form text.

Registrant Information ^* - indicates required field

Date:

First Name:^*

Last Name:^*

Degree/Occupation:^*

Last 4 digits of SS#
(US Registrants Only):

Preferred Mailing Address:

Address:^*

City:^*

State:^*

Zip/Postal Code:^*

Country:

Work Phone:

Cell Phone:

E-mail:

Registrant Type:^*

Conference Registration Fee (see fee schedule):^* $

Workshop Choices: (limited to 40 members per workshop)
Clinical Care & Toxicology (2 Days) $50.00 US
Trauma Life Support (2 Days) $50.00 US
Emergency Radiology $35.00 US
Pediatric Emergencies $35.00 US
Electrocardiogram (1 Day) $25.00 US
Paramedics/Nursing (1 Day) $30 US
Paramedics/Nursing & ECG (2 Days) $35.00 US
Radiology & ECG (2 Days) $50.00 US

Workshop Registration Fee:^* $

Credit Card:^*

Expiration Date:^*

Card Number:^*

3-digit CCV Code:^*

Billing Address:^*

Same as Mailing Address

Address:

City:

State:

Zip:

2008 EMCON Fee Schedule

	Up to July 31, 2008	Up to August 31, 2008	On-Site Registration
Delegates	$400.00 US	$425.00 US	$450.00 US
Postgraduates/Interns/Residents	$300.00 US	$325.00 US	$350.00 US
Nurses/Paramedics	$300.00 US	$325.00 US	$350.00 US
Faculty/AAEMI Members	$300.00 US