Registration Form. Page 1. *Denotes a required field ABA # * r Dr. r Mr. r Mrs. r Ms. SOAP Member ID # ASA Member ID #
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1 Page 1 *Badge Name (first name to appear on the first line of the badge) *First Name MI *Last Name *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 26, 2017 will be refunded less a $100 administrative fee. No refunds will be made after April 26, 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: Registration is Available Online at Registration - Page 1
2 Page 2 *First Name MI *Last Name *Business Phone Number Mobile Phone Number * Registration Fees* General Registration includes one ticket to the Welcome Reception, Continental Breakfasts, Breaks, Friday Lunch and T-shirt. Early Discounted Advanced Reg ONSITE ONLY Rate through Rate through After April 26, 2017 SOAP Member Fees: April 11, 2017 April 26, 2017 r SOAP Member... $695...$745...$795 r SOAP Resident, Fellow, Student... $495...$545...$595 *Please circle your status above. r SOAP Retired/Lifetime Members - Complimentary Registration* *Please note, to qualify for this registration, you must be a SOAP Retired Member or Lifetime Member and have 20+ years of SOAP Membership. SOAP Non-Member Fees: r OASAO, OAA, SMFM, NASOM Member... $795...$845...$895 (SOAP Non-Member) *Please circle applicable society membership(s) above. r Non-Member... $895...$945...$995 One Day Registration (Available onsite only) Thursday, Friday, Saturday OR Sunday - $350 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 SOAP Member and Non-Member Physician...$495 SOAP Member and Non-Member Resident/Fellow/Student...$495 *T-Shirt (included in registration fee) Please indicate size: q XXL q XL q Large q Small q Medium 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 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... General Registration Subtotal (please transfer amount to page 1)
3 Page 3 World Bank Classifications (2016) 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 *First Name MI *Last Name *Business Phone Number Mobile Phone Number * Special Sessions Wednesday, May 10, 2017 r Morning Use of Ultrasound in Obstetric Anesthesia Workshop, 8:00 a.m. 12:00 p.m. (limited to 24)...$295 r Morning Patient Safety Workshop: Leading Systems Change, 8:00 a.m. 12:00 p.m. (limited to 50)...$295 r Afternoon Focused Cardiac Ultrasound Workshop, 1:00 5:00 p.m. (limited to 36)...$295 r Afternoon Becoming a Successful Obstetric Anesthesiology Leader Workshop, 1:00 5:00 p.m. (limited to 50)...$295 r Afternoon Chinese Symposium on Obstetric Anesthesia, 1:00 5:00 p.m... Complimentary Social Events Special Sessions Subtotal Welcome Reception, Wednesday, May 10, 2017, 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 fee. SOAP Annual Meeting Banquet, Friday, May 12, 2017, 6:00 10:00 p.m. r I will attend the SOAP Banquet... Number of adults x $125 Number of children under 18 years x $60 Social Events Subtotal Informal Social Event Beer Tasting in Seattle (includes ticket for one complimentary beer) r I will attend this event... $10 x number of people Informal Event Subtotal Optional Fitness Events 5K Fun Run - Friday, May 12, 2017 r I will attend this event...$25 Donation to the Endowment Fund x number of people 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 Phone: administering clinical anesthesia, CRNA, AA)... $ Fax: q Retired Membership... $ info@soap.org q Medical Student Membership... $25.00 q Resident Membership*... $65.00 q Fellow Membership... $65.00 Residency/Fellowship ends: month year $ Total Membership Amount *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 SOAP2017 when signing up for an IARS membership ( Additional Subscriptions: q OAD- $80.00 q OAD International- $90.00 (For International Members ONLY) $ 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 $ SOAP Endowment Fund q Check or Money Order (made payable in U.S. dollars to $ Total Enclosed the Society for Obstetric Anesthesia and Perinatology) q Visa q MasterCard q Discover q AMEX Credit Card Number Expiration Date Name on Card Signature
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