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2015 Conference Registration
Please PRINT CLEARLY, information used for name badge and conference registration, ALL FIELDS REQUIRED.
Name:_____________________________________________________________ Title: PA-C _______________
Address:___________________________________________________________ Phone: (______) ______ - _________
City/State/Zip:_______________________________________________________ Work Phone: (______) ______ - _________
Ext:_________
E-mail:_____________________________________________________________________________ (required to receive registration confirmation)
Specialty:__________________________________________________________
Diet Requests: □ No Restriction (default)
□ Kosher
□ Vegetarian
NCCPA#:______________________
□ Vegan
□ Gluten-Free
Conference Tuition (includes meals)
Postmarked by:
9/18/2015
10/9/2015
On-Site
PSPA Member (#:_______________)
$420
$470
$520
$_____________
Constituent Chapter Member (State:____, #____________)
$420
$470
$520
$_____________
Conference & Membership (complete membership application)
$555
$605
$655
$_____________
Non-member of any constituent chapter
$570
$620
$670
$_____________
$155/Day
$185/Day
$205/Day
$_____________
$80
$110
$140
$_____________
$180/Day
$205/Day
$230/Day
$_____________
$110
$140
$170
$_____________
Daily Conference Rates
Member:
□ Wednesday □ Thursday
□ Friday
□ Saturday
Non-member:
□ Wednesday □ Thursday
□ Friday
□ Saturday
Workshops - $40/Session (MUST choose 1st and 2nd choices)
Thursday 7:00 AM - 9:00 AM
_____ Wound Care Treatment Options
_____ Radiology Imaging
Thursday 10:00 AM - 12:00 PM
_____ Arterial Blood Gases/Pulmonary Function
Thursday 4:30 PM - 6:30 PM
_____ Extremity Splint Application
_____ Child Abuse Training
$_____________
Friday
7:00 AM - 9:00 AM
_____ EKG Interpretation
_____ Wilderness Medicine
$_____________
Friday
10:00 AM - 12:00 PM
Friday
4:00 PM - 6:00 PM
_____ Art of Suturing
N/A
$_____________
N/A
_____ Concussion Management
$_____________
$_____________
_____ Chronic Kidney Disease
$_____________
NO REFUNDS for workshops unless both choices are full when registering.
Guest Fees (guests of registered conference attendees only)
ALL meals/events - $100
Guest Name: _______________________________________________________
OR SEPARATELY
□ Auction Reception - $40
□ Student Challenge Bowl - $15
$_____________
$_____________
Additional Items / Costs
PSPA 2015 Annual Charity - Community Shelter Services
Fun Run / Walk / Bike
□ Participate & T-Shirt - $15
□ Sponsor a Student Fund - $20
$_____________
□ T-Shirt Only -$10
Shirt Size: □ S □ M □ L □ XL □ XXL
$_____________
$_____________
□ Travel Mug - $10
□ Faculty Forum (Free)
TOTAL ENCLOSED
$___________
Online registrations available at www.pspa.net until October 9, 2015. NO REGISTRATIONS (mailed, e-mailed, faxed) will be accepted
after October 9, 2015. Please register on site after October 9, 2015 - Thank you!
□ Check #______________
Personal or Business (payable to PSPA)
□ American Exp □ Master □ Visa
Account # _________ - _________ - _________ - _________
Cardholder’s Name:___________________________________________
Exp Date: ______ /__________
Signature:________________________________________
Mail registrations to: PSPA, c/o Cindy Cicconi, P.O. Box 247, Hummelstown, PA 17036
Fax registrations accepted for credit card payments only at (717) 220-1190, DO NOT mail original to avoid duplicate charges.
If registration confirmation is not received within 2 weeks, please e-mail [email protected].
CANCELLATION POLICY: Cancellations until 10/9/2015 will be refunded minus $50 administration fee. NO REFUNDS after 10/9/2015.
NO REFUNDS for guest fees.
QUESTIONS? Call PSPA at (724) 836-6411 or e-mail: [email protected]