*City *State/Province *ZIP/ Postal Code *Country

Transcription

1 Page 1 *Badge Name (first name to appear on the first line of the badge) *Degree *Specialty *Affiliation (Organization) *Mailing Address *City *State/Province *ZIP/ Postal Code *Country *Business Phone Number Mobile Phone Number Fax Number * Twitter Handle *Is this your first time attending the SOAP Annual Meeting? r Yes r No *Which of the following best describes your medical practice environment? (Please select one) r Academia r Private Practice r Consulting r Large Group Practice r Retired r Hospital-based r Other Special Needs r I will require special accommodations (also contact the SOAP Administrative Office at info@soap.org or ) to provide details of your needs r Please check here for vegetarian meals r Please check here for kosher meals r Please check here for gluten-free meals *How did you hear about this meeting? (Please select one) r From Colleague r Announcement r Journal Ad r SOAP Member r Another Society s Website/Newsletter r Other: Registration Fees (Please see page two and three for details and pricing.) Total from Page 2 Total from Page 4 Grand Total Cancellation Policy Cancellations received in writing through April 25, 2018 will be refunded less a $100 administrative fee. No refunds will be made after April 25, Method of Payment: r Visa r MasterCard r AMEX r Discover r Check # (payable to SOAP in U.S. funds drawn from a U.S. bank) Card Number Expiration Date Name on Card Signature Send complete registration forms (pages 1, 2 and 4) with payment to: Society for Obstetric Anesthesia and Perinatology (SOAP) 6737 W. Washington St., Suite 4210 Milwaukee, WI Phone: (414) Fax: (414) Registration is Available Online at Registration - Page 1

2 Page 2 *Business Phone Number Mobile Phone Number * Registration Fees* General Registration includes one ticket to the Welcome Reception, Continental Breakfasts, Breaks, Saturday Lunch and T-shirt. Early Discounted Advanced Reg ONSITE ONLY Rate through Rate through After April 25, 2018 SOAP Member Fees: April 11, 2018 April 25, 2018 r SOAP Member... $ $795...$845 r SOAP Fellow**... $ $570...$595 r SOAP Resident, Medical Student... $ $370...$395 Please circle your status above. r SOAP Retired Members... $ $370...$395 Please note, to qualify for this registration, you must be a SOAP Retired Member and have 30+ years of SOAP Membership. SOAP Non-Member Fees: r OASAO, OAA, SMFM, NASOM Member... $ $895...$945 Please circle applicable society membership(s) above. r Non-Member... $ $995...$1045 One Day Registration (Available Onsite Only)... Thursday, Friday, OR Sunday - $345 r Saturday Clinical Track (SOAP Member or Non-Member)...$ $345...$345 The Clinical Track is included with the general registration fees. Special Registration Fees - Middle and Low Income Countries (World Bank Classification) Attendees are eligible for middle and low income country registration, providing they meet all the following criteria: Reside in a country in the middle or low income category Working (or previously working) in a country in the middle or low income category Have a postal address in the middle or low income category which is detailed r SOAP Member and Non-Member Physician...$520 r SOAP Member and Non-Member Resident/Fellow/Student...$520 *T-Shirt (included in registration fee) Please indicate size: q Small q Medium q Large q XL q XXL q I do not want a t-shirt Additional shirts may be purchased onsite for $10 while quantities last. Guest(s) Registration Fees General Adult Guest Registration General Adult Guest Registration includes one ticket to the Welcome Reception, Sunrise Beach Yoga and a t-shirt. # of adult guest(s) $ x $150 Name(s) of spouse/adult guest(s)... *T-Shirt (included in guest registration fee) Please indicate size: q Small q Medium q Large q XL q XXL q I do not want a t-shirt General Children (under 18 years) Guest Registration # of children...$ x $20 Name(s)/Age(s) of children... ** SOAP Fellow Members who do not receive departmental funds for educational purposes from their institution or hospital may be eligible for a discounted rate until April 6, Please visit for more information. General Registration Subtotal (please transfer amount to page 1)

3 Page 3 World Bank Classifications (2017) Middle Income Countries Attendees are eligible for middle income country registration providing they meet all the following criteria: Reside in a country in the middle income country category Working (or previously working) in a country in the middle income country category Have a postal address a country in the middle income country category which is detailed at time of registration Albania Algeria American Samoa Angola Armenia Azerbaijan Bangladesh Belarus Belize Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Bulgaria Cabo Verde Cambodia Cameroon China Colombia Congo, Rep. Costa Rica Côte d Ivoire Cuba Djibouti Dominica Dominican Republic Ecuador Egypt, Arab Rep. El Salvador Equatorial Guinea Fiji Gabon Georgia Ghana Grenada Guatemala Guyana Honduras India Indonesia Iran, Islamic Rep. Iraq Jamaica Jordan Kazakhstan Kenya Kiribati Kosovo Kyrgyz Republic Lao PDR Lebanon Lesotho Libya Macedonia, FYR Malaysia Maldives Marshall Islands Mauritania Mauritius Mexico Micronesia, Fed. Sts. Moldova Mongolia Montenegro Morocco Myanmar Namibia Nicaragua Nigeria Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Romania Russian Federation Samoa São Tomé and Principe Serbia Solomon Islands South Africa Sri Lanka St. Lucia St. Vincent and the Grenadines Sudan Suriname Swaziland Syrian Arab Republic Tajikistan Thailand Timor-Leste Tonga Tunisia Turkey Turkmenistan Tuvalu Ukraine Uzbekistan Vanuatu Venezuela, RB Vietnam West Bank and Gaza Yemen, Rep. Zambia Low Income Countries Attendees are eligible for low income country registration providing they meet all the following criteria: Reside in a country in the low income country category Working in a country in the low income country category Have a postal address a country in the low income country category which is detailed at time of registration Afghanistan Benin Burkina Faso Burundi Central African Republic Chad Comoros Congo, Dem. Rep. Eritrea Ethiopia Gambia, The Guinea Guinea-Bissau Haiti Korea, Dem. Rep. Liberia Madagascar Malawi Mali Mozambique Nepal Niger Rwanda Senegal Sierra Leone Somalia South Sudan Tanzania Togo Uganda Zimbabwe Registration - Page 3

4 Page 4 *Business Phone Number Mobile Phone Number * Special Sessions Wednesday, May 9, 2018 r Morning Use of Ultrasound in Obstetric Anesthesia Workshop, 8:00 a.m. 12:00 p.m. (limited to 45)... $295 r Morning SOAP Education Workshop: Innovations in Medical Education, 8:00 a.m. 12:00 p.m... $295 r Morning SOAP Research Workshop: Opioids in the Obstetric Population, 8:00 a.m. 12:00 p.m... $295 r Afternoon Focused Cardiac Ultrasound Workshop, 1:00 5:00 p.m. (limited to 24)... $295 r Afternoon SOAP Education and Patient Safety Workshop: Expert Communication Strategies, 1:00 5:00 p.m... $295 r Afternoon Latin American Symposium on Obstetric Anesthesia, 1:00 5:30 p.m... Complimentary r Afternoon Chinese Symposium on Obstetric Anesthesia, 1:00 5:00 p.m... Complimentary Thursday, May 10, 2018 r Lunch Discussion Table: Overcoming Obstacles to Patient Safety on Labor and Delivery, 12:15-1:30 p.m... $90 r Lunch Discussion Table: Why is it Important to Implement an ERAS Program for your Cesarean Section Patients?, 12:15-1:30 p.m... $90 r Lunch Discussion Table: Critical Care Scenarios: Improving Obstetric Outcomes, 12:15-1:30 p.m... $90 Social Events Special Sessions Subtotal Welcome Reception, Wednesday, May 9, 2018, 6:00 8:00 p.m...$95 *One ticket is included in the Full SOAP Conference Registration for attendees and one ticket is included in the Guest Registration. SOAP Annual Meeting Banquet, Saturday, May 12, 2018, 6:00 10:00 p.m. r I will attend the SOAP Banquet...Number of adults x $150 Number of children under 18 years x $60 Social Events Subtotal Optional Fitness Event Sunrise Beach Yoga, Friday, May 11, 2018, 7:00 8:00 a.m. Complimentary r I will attend this event... number of people x Special Sessions, Social Events and Optional Fitness Events Subtotal (please transfer amount to page 1) Registration - Page 4

5 Membership Application Please print or type. Please complete all sections. I hereby make application for: 6737 West Washington Street q Active Membership (M.D., D.O., M.B.B.S.)... $ Suite 4210 q Associate Membership (Physicians or scientists not engaged in Milwaukee, WI administering clinical anesthesia, CRNA, AA)... $ Phone: q Retired Membership... $65.00 Fax: q Medical Student Membership R...Complimentary info@soap.org q Resident Membership v...complimentary q Fellow Membership R...Complimentary Residency/Fellowship ends: month year $ Total Membership Amount R To receive complimentary membership for a Medical Student, Resident or Fellow you MUST COMPLETE & RETURN FORM accordingly. v If Resident Membership, need Program Director s signature: As a member of SOAP, you can obtain $20 off a membership with the IARS. Use the discount code SOAP2018 when signing up for an IARS membership ( Additional Subscriptions: q OAD- $80.00 q OAD International- $90.00 (For International Members ONLY) q IJOA- $ $ Total Subscription Amount Last First Middle Initial q M.D. q D.O. q M.B.B.S. q Other: Date of Birth: Preferred Mailing Address: q Home q Business University/Hospital Business Mailing Address City State/County ZIP/Postal Code Phone Fax Home Mailing Address City State/County ZIP/Postal Code Specialty: q Anesthesia q OB q Peds q Other Board Certification: q Yes q No Type of Practice: q Academic q Private, # of partners/colleagues q Other Interest in OB Anesthesia (check all that apply): q High Risk q Pain Control q Administrative q Research q Perinatology q Education q Other I am also a member of: q ASA q AMA q NASOM q SMFM q ACOG q AAP q Other Donation to the SOAP Endowment Fund - this contribution is tax deductible. q Bronze Level - $25.00 q Silver Level - $50.00 q Gold Level - $ q Gertie Marx Patron Level - $ q Other: If you wish to donate another amount, please contact the SOAP office at Payment Options q Check or Money Order (made payable in U.S. dollars to the Society for Obstetric Anesthesia and Perinatology) $ SOAP Endowment Fund $ Total Enclosed q Visa q MasterCard q Discover q AMEX Credit Card Number Expiration Date Name on Card Signature