CHECK PAYMENT REGISTRATION FORM
•
Register on or before June 22nd to
receive early registration fees.
•
No refunds will be given for
cancellations received after July 6th.
•
Questions? Please call 508-743-8511
This is a 3-page form and cannot be processed without 3 pages per registrant.
Part 1: REGISTRATION INFORMATION
First Name:___________________________________ Last Name:__________________________________ Badge Name:_______________________________________________
Title:_________________________________________________________________________ Degree:__________________________________________________________________
Company/Organization:________________________________________________________________________________________________________________________________
Department:___________________________________________________________________________________________________________________________________________
Mailing Address 1:______________________________________________________________________________________________________________________________________
Mailing Address 2:______________________________________________________________________________________________________________________________________
City:________________________________________________________ State:_____________ Postal Code:______________________ Country:____________________________
Phone:___________________________________________________________________________________Ext:___________________________ Fax:____________________________
E-mail (must be included to receive confirmation):_______________________________________________________________________________________________________
Emergency Contact Name:____________________________________________________ Phone:__________________________________________________________________
Are you attending the AAPM Meeting representing another society? If yes, please give society name:______________________________________________________
If you will require special services while attending the meeting, please contact Karen at karen@aapm.org (please respond by June 22, 2016)
o I give permission for AAPM to release my e-mail address to exhibitors at the 2016 AAPM Annual Meeting and Technical Exhibits. Since you have given
permission for AAPM to release your e-mail address to vendors from the 2016 AAPM Annual Meeting and Technical Exhibits, which products are you
interested in? o Therapy Physics o Nuclear Medicine Physics o Imaging Physics _ o Health Physics
o I do not give my permission for AAPM to release my e-mail address to exhibitors at the 2016 AAPM Annual Meeting and Technical Exhibits unless I allow my
badge to be scanned by an exhibitor at the event.
o Photograph Consent: By checking this box, you understand that registration and attendance at, or participation in this AAPM Meeting, constitutes
an agreement by the registrant to permit show management’s use and distribution (both now and in the future) of the registrant’s image or voice in
photographs, videos, and other electronic reproductions of such events.
Please indicate if you have any of the following special dietary requirements (Monday Lunch Voucher, Tuesday Lunch Voucher and Thursday Box Lunch
only). Please note – these items are not included in all registration categories: o Gluten Free o Vegetarian o Kosher
Part 2: DEMOGRAPHIC INFORMATION
1. Please identify your primary employment function:
o 01 Clinical
o 07 Retired
o 02 Academic Research/Development
o 08 Teaching
o 03 Customer Support
o Other_______________
o 04 Marketing/Sales
o 05 Regulatory
o 06 Commercial Research/Development
2. Please identify the nature of your primary employer:
o 01 Private Health Care Facility
o 05 Government/Not Health Care
o 08 Commercial
o 02 Physician Practice Group
o 03 Medical Physics Practice Group
o 06 Academic Health Care Facility/Med School
o 09 Retired
o Other_______________
o 04 Government Health Care Facility
o 07 Academic/Not Health Care
Part 3: PACKAGE SELECTION
Weekly Registration (except Emeritus, all include a ticket to: the Awards Ceremony and
Reception, Night Out, and access to the Exhibit Hall)
Discounted on or
Before 6/22/2016
After
6/22/2016
o Member Weekly
$695
$925
o Emeritus Member (Night Out ticket not included – may be purchased separately)
$130
$130
o Member Resident Weekly OR o Junior Member Weekly (please check one)
$295
$295
o Non-Member Weekly
$1,390
$1,620
o Non-Member Resident (must provide letter – see special registration type qualifications on website)
$385
$385
o AAMD Member Weekly Must Include Promotional Code:
$695
$925
o Member Student Weekly
$236
$236
o Non-Member Student Weekly (must provide letter – see special registration type qualifications on website)
$236
$236
Daily Registration (You may purchase tickets separately to Social Events. Daily attendees are only eligible for
continuing education credits for evaluated sessions held on the registered day(s) of participation.)
o Thursday (1/2 price)
0
Days______x
$340 (Th/$170)
Total $ 0
o Sunday o Monday o Tuesday o Wednesday o Thursday (1/2 price)
0
Days______x
$680 (Th/$340)
Total $ 0
Student Daily (non-members must provide letter – see qualifications on website)
o Sunday o Monday o Tuesday o Wednesday o Thursday (1/2 price)
0
Days______x
$25 (Th/$12)
Total $ 0
o Member Resident OR o Junior Member Daily (please check one)
o Sunday o Monday o Tuesday o Wednesday o Thursday (1/2 price)
0
Days______x
$90 (Th/$45)
Total $ 0
Non-Member Resident Daily (must provide letter – see qualifications on website)
o Sunday o Monday o Tuesday o Wednesday o Thursday (1/2 price)
0
Days______x
$180 (Th/$90)
Total $ 0
AAMD Daily Must Include Promotional Code:
o Sunday o Monday o Tuesday o Wednesday
0
Days______x
$340 (Th/$170)
Total $ 0
Member Daily
o Sunday
Non-Member Daily
o Monday
o Tuesday o Wednesday
o Thursday (1/2 price)
PAGE 1 SUBTOTAL:
$ 0
CHECK PAYMENT REGISTRATION FORM | Registrant’s Name:_________________________________________________ Page 2 of 3
Part 4: MISCELLANEOUS ITEMS
Other Activities/Meetings
o Diagnostic Physics Review Course (see reg type qualifications on website)
$195
$100 student rate
o Therapy Physics Review Course (see reg type qualifications on website)
$195
$100 student rate
o Nuclear Medicine Review Course (see reg type qualifications on website)
$115
$100 student rate
o Nuclear Medicine & Diagnostic Physics Review Course package (see reg type qualifications on website)
$250
$200 student rate
o Annual Meeting of the Radiotherapy Service Association (RSEA)
$135
$195 (after 6/22)
$25
o SDAMPP AM – Saturday, 7/30 • 8:00 am – 11:00 am (Followed by the SDAMPP Business Meeting)
$15 Students/Residents/Junior Members
o Women Physicists’ Luncheon – Tuesday, 8/2 • 12:15 pm
$25 Full Registrations
N/C
o New Member Symposium (joined after June 2013) – Tuesday, 8/2 • 4:30 pm
o TG100 Certificate of Completion Course: Application of Risk Assessment Methods to Radiotherapy
Quality Management – Wednesday, August 3, 2016 – 7:30 am - 6:00 pm;
Thursday, August 4, 2016 – 12:15 pm - 2:50 pm (attendance is optional)
Included with registration: • USB stick and downloadable file of speaker presentations
• Reserved seating • Participation Device (PD) • Framed certificate of participation
Call 508-743-8511 to register. Click here to see price structure.
OTHER ACTIVITIES/MEETINGS TOTAL:
$0
Companion Registration – Companions ages 12 through 17 will be allowed in the Exhibit Hall but must be accompanied by a registered attendee at all times.
o Age 21 & over
Name(s):
Qty ______ x $15
o Age 12-20
Name(s):
Qty ______ x $0
o Age 11 & Under
Name(s):
Qty ______ x $0
COMPANION REGISTRATION TOTAL:
Total $ 0
$ 0
Social Events - ADDITIONAL TICKETS (the Awards Ceremony & Night Out tickets are included with Weekly Registration)
$16
Qty ______ x $16 ea
Total $ 0
$20
Qty ______ x $20 ea
Total $ 0
o Night Out at The Newseum (21 and over) – Tuesday, 8/2 • 6:30 pm - 10:00 pm
$106
Qty ______ x $106 ea
Total $ 0
o Night Out at The Newseum (ages 12 - 20) – Tuesday, 8/2 • 6:30 pm - 10:00 pm
$88
Qty ______ x $88 ea
Total $ 0
o Night Out at The Newseum (ages 3 - 11) – Tuesday, 8/2 • 6:30 pm - 10:00 pm
$75
Qty ______ x $75 ea
Total $ 0
o Night Out at The Newseum (2 and under) – Tuesday, 8/2 • 6:30 pm - 10:00 pm
Free
Qty ______ x Free
Free
o Students and Trainees Night Out: All-inclusive Experience at the DC United Soccer Game!
Sunday, 7/31 • 8:00 pm - 10:30 pm
$35
Qty ______ x $35 ea
Total $ 0
o WGSTR Student and Trainee Lunch – Sunday, 7/31 • 11:30 am - 1:00 pm
$10
Qty ______ x $10 ea
Total $ 0
SOCIAL EVENTS TOTAL:
$0
PAGE 2 SUBTOTAL:
$0
o Awards Ceremony & Reception – Monday, 8/1 • 6:30 pm – 8:30 pm
o Sun Nuclear Annual 5K Run/Walk in honor of Dr. Charles Lescrenier – Tuesday, 8/2 Start time 6:00 am
(Capital Crescent Towpath; fee includes t-shirt) Sun Nuclear wishes to donate all proceeds from the event to the AAPM
Education and Research Fund.
Please specify if your donation should go to: o General Education Fund
T-shirt size(please specify number of each): _____S
_____M
_____L
o Education & Research Fund
_____XL
_____XXL
Category (please specify number of participants in each category):
o Male 12 & over x ____
o Female 12 & over x ____
o Male 11 & under x ____ o Female 11 & under x ____
CHECK PAYMENT REGISTRATION FORM | Registrant’s Name:_________________________________________________ Page 3 of 3
Exhibit Hall Guided Tours
Join a guided tour of vendors offering either microdosimeters for therapy applications or dosimeters for diagnostic imaging quality control. Tours will be lead by
AAPM members and will include a short introduction. SAMs credit will be offered. Pre-registration required.
o Exhibit Hall Guided Tour - Therapy 1 - Microdosimeters – Tuesday, 8/2 • 1:45 pm
Free
Qty ______ x $0 ea
Free
o Exhibit Hall Guided Tour - Therapy 2 - Microdosimeters – Wednesday, 8/3 • 10:15 am
Free
Qty ______ x $0 ea
Free
o Exhibit Hall Guided Tour - Imaging 1 - Dosimeters for QC – Tuesday, 8/2 • 1:45 pm
Free
Qty ______ x $0 ea
Free
o Exhibit Hall Guided Tour - Imaging 2 - Dosimeters for QC – Wednesday, 8/3 • 10:15 am
Free
Qty ______ x $0 ea
Free
SAMs Rental
Participation Device (PD): Click here for more info on SAMs. If you require MOC as defined by ABR,
you will need to rent the PD to verify your attendance at SAMs sessions.
SAMs TOTAL:
o $10 w/ $175 credit card deposit on-site
$0
Virtual Library Presentations – USB Flash Drive Pre-Sales (all prices below include shipping)
Selected presentations given during the 58th AAPM Annual Meeting and Exhibition will be available on USB Flash Drive following the meeting. Presentations will include: Streaming audio and slides of
the presentations. A complete list of content will be available at the Member Services desk in Washington, DC. USB Flash Drives are PC and MAC compatible only. Orders will be shipped 4 – 6 weeks
following the meeting.
Qty ______ x $120.00 ea
o USB Flash Drive (Pre-Meeting purchase. Price includes regular UPS shipping)
Total $ 0
o Expedited shipping – United States
$15
o Expedited shipping – International
$65
USB FLASH DRIVE TOTAL
$0
PAGE 3 SUBTOTAL:
$0
FINAL REGISTRATION TOTAL
$0
Part 5: REGISTRATION PAYMENT
Check Number:_______________________________________________________________________________________________ Check Total:_____________________________
Part 6: HOW TO SUBMIT YOUR REGISTRATION FORM(S)
Register by Mail:
AAPM 2016
c/o Convention Data Services
107 Waterhouse Road
Bourne, MA 02532
AAPM Federal ID #:
23-7057224
Payment and Cancellation Policy:
PLEASE NOTE!!! If you have registered at the early rate
and are paying by check, your payment must be
RECEIVED no later than June 22, 2016. If we do not
receive your payment for the early registration fees
by June 22, your registration type will be changed to
reflect the late registration type and fee.
Clear Form
Please call the AAPM Call Center with any questions:
508-743-8511
Fees for registration will be refunded in full if written notice
of cancellation is received by July 6, 2016. No refund will
be given for cancellations received after July 6. Please
send your written request for cancellation and refund to
aapm@xpressreg.net
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