Registering for ACG 2015 is easy. You can register online, by fax, or by mail. ONLINE www.acgmeetings.gi.org FAX 301-263-9025 Step 1 • Contact Information Provide your contact information (including email address) on the Registration Form. Step 2 • Course Selections To register, choose one of the educational programs under your corresponding registration category. You may also select one or more of the optional programs offered on Friday, October 16. Please circle the Friday Program(s) you would like to attend. Note: If you select the 3-day Clinical Review, you do not need to register for the GI Pathophysiology Course or the What’s New in GI Pharmacology Course. Registrants of the Postgraduate Course and the Annual Scientific Meeting may choose to receive either a printed copy of the meeting syllabus or a PDF of the syllabus on a USB drive. There is a separate charge to purchase both the USB version and the printed version of either syllabus. Pre-registration deadline: Friday, October 9, 2015 For those sending registration via U.S. mail, please postmark your registration no later than Monday, September 28, 2015. MAIL American College of Gastroenterology 6400 Goldsboro Road, Suite 200 Bethesda, MD 20817-5842 Step 3 • Optional Learning Luncheons and Breakfast Sessions If you’ve selected the Postgraduate Course, you have the option of attending up to two of the 24 Postgraduate Course Learning Luncheons (one each day) to be offered. The cost is $75 each. Learning Luncheons are offered on Saturday and Sunday, October 17 and 18. You may choose one Learning Luncheon each day. Learning Luncheons are optional. Since Learning Luncheons fill up fast, please indicate your top five choices for each day by numbering them 1-5. We will make every effort to accommodate your top choice. If you signed up for the Annual Scientific Meeting, you have the option of attending up to three of the 16 Annual Scientific Meeting Breakfast Sessions offered on Monday, October 19, Tuesday, October 20, and Wednesday, October 21. The cost is $60 each. A syllabus on USB containing all ACG 2015 Breakfast Session handouts will be provided to attendees registered for any Breakfast Session. You may choose one Breakfast Session each day. Breakfast Sessions are optional. Since Breakfast Sessions fill up fast, please indicate your top five choices for each day by numbering them 1-5. We will make every effort to accommodate your top choice. Step 4 • Additional Offerings ACG offers additional programs or materials to certain attendees. •Fellows-in-training may sign up for the Trainees luncheon on Sunday, October 18. The cost is $35. This event is available only to GI fellows-in-training. Step 5 • Payment Registration selections are now complete. If you choose to mail or fax the registration form, please complete the payment information on the form and sign the form. 36 ACG 2015 Registration Form Pre-registration will remain open until Friday, October 9, 2015. For those sending registration via U.S. mail, please postmark your registration no later than Monday, September 28, 2015. Mail to: ACG, 6400 Goldsboro Road, Suite 200, Bethesda, MD 20817-5842 Fax to: ACG at 301-263-9025. Fax with credit card number and signature. Web: Register at www.acgmeetings.gi.org. Cancellation: Written notice of cancellation and requests for refunds must be received by the College’s office by September 25, 2015. After this day, no refunds will be possible. Please complete sections 1-5. Please print clearly. Registration cancellations are not accepted by telephone. An explanation must be provided in writing. There will be a $50 administrative fee assessed for cancellation of any paid event. Refunds will be issued after the meeting. See Cancellation Policy on page 34. ADA Compliance: Attendees of the ACG Annual Meeting who need additional reasonable accommodations or who have special needs should contact the ACG office at 301-263-9000 no later than September 25. 1. personal Information First name Last Name MUST circle all that apply: MD* DO* PhD Mailing address Home address PANP RN LPN PharmD Other *Please enter your 10-digit NPI number (required if U.S. physician) Look up your NPI number at npinumberlookup.org. Work address City State/Province Zip / Postal Code Phone Country Fax Email (required for meeting confirmation) Spouse / Guest name, only if attending meeting 2. Registration fees I am currently an ACG member. My application* for membership is attached. I have registered below at the member rates. (For membership information or to download a membership application, visit www.gi.org.) * Registration will not be processed without membership application. I am an ACG 2015 presenter: oral paper PA / N le Res P / tte id Re (in Gu Phy Al r f en sid Pe P clu s M lie es ic ro t/ rs A / en em d de t P ia m Tr on N t/T a n sF be He hy / PD in ne P / Pr rs al AC si Ex e M rain ac l ( Al ve e b ci hi (e th em ee G A e. lie tic r a b ( . P i fy m n / ito g. e g an CG / b d e . C in u er a Ph r / RN rso RN H d M M st g nd e M e o an G n ar u st at a ,L n , f A id AC m l LP th at ta m ag e e P poster b a l CG te us c D st G) e N N er r / ) ) ) h Circle fee(s) based on attendee type a PG Course and Annual Meeting, Oct. 17–21 PG Course Onlya, Oct. 17–18 Annual Meeting Only, Oct. 19–21 3-day Clinical Review, Oct. 16–18, includes PG Coursea, GI Pathophysiology, and GI Pharmacology 3-day Clinical Reviewa PLUS Annual Meeting, Oct. 16–21 ACG MEMBERS NON-MEMBERS $425 $425 $0 $600 $0 $0 $0 $200 $275 $275 $0 $450 $750 $550 $300 $750 $200 $200 $0 $425 $575 $500 $150 $725 $575 $500 $150 $725 $600 $200 $450 $850 $425 $800 $800 $200 $200 $275 $150 $395 $160 $160 $0 $150 $200 $175 $175 $200 $150 $200 $225 $225 $300 $175 $495 $225 $225 $300 $175 $250 $225 $225 $300 $175 $250 $225 $225 $300 $175 $250 Optional Friday Programs, October 16 GI Pathophysiology; half-day/am (included in 3-Day Clinical) GI Pharmacology; half-day/pm (included in 3-Day Clinical) Practice Management; full day GI Recertification; half-day/pm (includes 10-point SAPMOC) ASGE Postgraduate Course; full day a b Includes 10-point PG+MOC module. Resident/Trainee non-member registrations will not be processed without a letter from the Program Director verifying status. Postgraduate Course attendees Please indicate Syllabus preference. Print version only........ FREE USB drive only............ FREE Print and USB................$30 2015ADV Annual Scientific Meeting attendees Please indicate Syllabus preference. Print version only........ FREE USB drive only............ FREE Print and USB................$30 37 3. optional sessions Learning Luncheons No refunds after September 25, 2015. $75 – Saturday Learning Lunch – pg course registrants only 11:55am – 1:10pm, October 17, 2015 Select top 5 choices and number them 1, 2, 3, 4 or 5. Rectal Problems: ‘Roids, Fissures, Tags, Dysfunction Refractory IBD Patient Current Indications and Use for EUS in 2015 Diverticular Disease—Another Chronic Colitis? Ugh! Liver Disease in Pregnancy Incorporate Quality Initiatives Into Your Practice Esophageal Function Testing in Practice Practical Pearls in the Care of the IBD Patient Liver Lesions: Evaluation and Management Flat, Large Colon Polyp Diagnosis, Management Luminal Neuroendocrine Tumors EMR, ESD and Advanced Polypectomy LL1 LL2 LL3 LL4 LL5 LL6 LL7 LL8 LL9 LL10 LL11 LL12 BREAKFAST SESSIONs No refunds after September 25, 2015. $60 – Monday Breakfast – annual meeting registrants only 6:00am – 7:00am, October 19, 2015 Select top 4 choices and number them 1, 2, 3 or 4. $60 – Tuesday Breakfast – annual meeting registrants only 6:00am – 7:00am, October 20, 2015 Select top 5 choices and number them 1, 2, 3, 4 or 5. Anorectal Disorders Large, Flat or Hiding: Know Your Enemy Gastroenterology and the Law Complex Cases in Pancreatology Complementary and Alternative Therapies Practical Approach to the Liver Zebras Celiac Disease: What Is New on the Horizon? The Ever-changing Waves of Esophageal Motility $75 – Sunday Learning Lunch – pg course registrants only 12:20pm – 1:35pm, October 18, 2015 Select top 5 choices and number them 1, 2, 3, 4 or 5. Non-Achalasia Esophageal Motility Disorders Decision Making in Hereditary Colon Cancer Managing IBD Through Childbearing Years Screening Your IBD Patient for Colon Cancer Impact of Public Policy Changes on the GI Practice Management of Ascities and Fluid Overload Capsule Endoscopy: What Is On the Horizon? Management of Fecal Incontinence Endoscopic Approaches to Perfs, Fistulas, Leaks Pelvic Floor Dysfunction How Can I Increase My Adenoma Detection Rate? Managing Benign, Malignant Biliary Strictures LL13 LL14 LL15 LL16 LL17 LL18 LL19 LL20 LL21 LL22 LL23 LL24 MONA MONB MONC MOND Not All Colitis Is Created Equal What the GI Needs to Know About Surgery for IBD Bariatric Endoscopy Applying the Gut Microbiome to Your Practice TUEE TUEF TUEG TUEH TUEI TUEJ TUEK TUEL $60 – Wednesday Breakfast – annual meeting registrants only 6:00am – 7:00am, October 21, 2015 Select top 4 choices and number them 1, 2, 3 or 4. Controversial Debates in Endoscopy Small Bowel, Large Problem What Your IBD Patient Really Wants to Know Hepatitis B: The Forgotten Virus WEDM WEDN WEDO WEDP NOTE: While space is limited for the Learning Luncheons and the Breakfast Sessions, we will make every effort to accommodate your top choice. Register early for best selection. 4. ADDITIONAL OFFERINGS I am registering for a breakfast and/or lunch, and require a: $35 – Trainees Luncheon 12:20pm – 1:35pm, October 18, 2015 You may not register for a Sunday Learning Luncheon if you register for the Trainees Luncheon. See page 23 for details. No refunds after September 25, 2015. Vegetarian meal Kosher meal Gluten free meal 5. payment Pay by check. Make checks payable in U.S. funds to ACG. Pay by credit card: VISA MasterCardAMEX Subtotal section 2: Credit Card #Exp. Date Subtotal section 3: Subtotal section 4: Name on Card 3 or 4 digit security code TOTAL DUE: Signature 38