Five Ways to Register
Online: ucaoa.org
Mail: UCAOA, 387 Shuman Blvd, Suite 235W, Naperville, IL 60563
Fax: 331-457-5439
Email: convention@ucaoa.org
Phone: 877-698-2262
2016 Fall Conference Registration Form
Gaylord Opryland Resort & Convention Center: September 29 – October 1, 2016
Attendee Name: Click here to enter text.
Name Preference for Badge: Click here to enter text.
Credentials:
☐ MD
☐ DO
☐PA
☐ NP
☐ RN
☐ CPC
☐ Other: Click here to enter text.
Professional Title (e.g. Owner, Medical Director): Click here to enter text.
Organization: Click here to enter text.
Address: Click here to enter text.
City: Click here to enter text. State: Click here to enter text. Zip/Postal Code: Click here to enter text.
Mobile Phone: Click here to enter text. Attendee Email Address: Click here to enter text.
Email Address for Receipt: Click here to enter text.
Emergency Contact Name: Click here to enter text. Emergency Contact Phone: Click here to enter text.
Are you registering with a group of four or more?
☐Yes
☐No
Are you a decision maker related to new products/services for your company?
☐Yes
☐No
How would you like to hear from the Exhibitors supporting us?
☐Mail only
☐Email and Mail
Are you a current member of UCAOA?
☐Yes
☐No
If you would like to join now, please check the type of membership
☐Individual $195
☐Physician $225
☐Student/Resident $75
☐Clinic Membership (Call for pricing)
If you answer yes, to either question below, please email convention@ucaoa.org with details.
Do you have food allergies?
☐Yes
☐No
Do you have a disability requiring accommodations to fully participate?
☐Yes
☐No
Conference | Thursday, Sept. 29 – Saturday, Oct. 1
The Fall Conference begins at 3pm with breakout sessions. On Thursday evening join our vendor supporters for a music-filled
opening reception in the Exhibit Hall. Breakouts will run all day Friday beginning with the opening Keynote starting at 7:45am and
end with a networking reception in the Exhibit Hall. Saturday morning starts with “can’t miss” breakout sessions at 8am and a
Southern Brunch in the Exhibit Hall. Breakouts conclude at 12:30pm.
(Pre-Con) Clinic Startup Fundamentals | Thursday, Sept. 29 | 8am-5:30pm
Thinking about opening an urgent care clinic? Attend this full-day course. You will be provided with great take-away information on
how to start your clinic. Class will begin at 8am and run continuously through 5:30pm. Attendees will eat lunch with the faculty for
more Q&A Opportunities.
(Pre-Con) Splinting and Casting | Thursday, Sept. 29 | 8:30am-5:30pm
Gain practical knowledge on how to apply and remove fiberglass and plaster splints and casts. Determine what the
appropriate splint is for the most common upper extremity injuries and understand the pros and cons of using plaster
versus fiberglass.
(Pre-Con) Musculoskeletal Exam | Thursday, Sept. 29 | 8:30am-12:30pm
Develop and enhance your skills for performing a detailed musculoskeletal exam. Providers get the opportunity to learn
the physical exam skills that focus on upper and lower extremities, and also other areas such as the back.
(Pre-Con) Joint Injections | Thursday, Sept. 29 | 1:30-5:30pm
This course introduces commonly performed musculoskeletal injections of the shoulder, knee and elbow for an urgent
care center. The use of various anesthetic agents and steroids is discussed . Proper needle size, fluid volumes, landmarks,
and techniques are practiced on simulated patients.
(Post-Con) Advanced Suturing | Saturday, Oct. 1 | 1:15-4:45pm
Designed for providers that are proficient in performing simple interrupted sutures and want to build on their skills. The
course covers multi-layer closure, vertical and horizontal mattress stitch, running subcuticular stitch, and the Z -Plasty
technique for difficult closures.
Attendee Name: Click here to enter text.
EARLY
(through 6/16/2016)
Conference
Non-member rate
$995
Clinic Startup Fundamentals
Non-member rate
$745
Splinting and Casting
Non-member rate
$895
Musculoskeletal Exam
Non-member rate
$520
Joint Injections
Non-member rate
$520
Advanced Suturing
Non-member rate
$520
Physician MD/DO CME Fee
REGULAR
LATE
(6/17 – 8/18/2016)
(8/19 – 9/21/2016)
Conference
Conference
Non-member rate
Non-member rate
$1095
$1195
Clinic Startup Fundamentals
Clinic Startup Fundamentals
Non-member rate
Non-member rate
$795
$895
Splinting and Casting
Splinting and Casting
Non-member rate
Non-member rate
$945
$995
Musculoskeletal Exam
Musculoskeletal Exam
Non-member rate
Non-member rate
$570
$620
Joint Injections
Joint Injections
Non-member rate
Non-member rate
$570
$620
Advanced Suturing
Advanced Suturing
Non-member rate
Non-member rate
$570
$620
Any physician claiming CME for this event, add $75
Member
Discount
- $195
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Group Discount
If you are registering with a group of 4 or more, subtract 20%
off tuition total
Reception Guest Pass(es)
Attendees may purchase a pass for up to three guests for to
attend the 9/29 & 9/30 Evening Exhibit Hall Receptions.
Please be aware guests must be at least 18 years old. Each
pass is $50.
Please list first and 1. Click here to enter text.
last name 2. Click here to enter text.
of guest(s) 3. Click here to enter text.
Membership - Joining now to receive member rates: ☐Individual $195 ☐Physician $225
☐Student/Resident $75
☐Clinic Membership (Call for pricing)
Any registration after September 21 will have a $100 walk-in surcharge added to your tuition.
TOTAL
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Attendee Name: Click here to enter text.
Payment: Registrations processed and tuition rates set upon receipt of payment. Please contact UCAOA if you have not received an
email confirmation within two business days.
☐ Check Enclosed (must be postmarked by 9/1) Check #: Click here to enter text.
☐ Visa ☐ MC
☐ AMEX
Card No: Click here to enter text.
Exp. Month/Year Click here to enter text. / Click here to enter text. CVV (security code): Click here to enter text.
Signature/Initials: Click here to enter text.
(By inserting your initials, you grant UCAOA to charge your credit card and accept/authorize the charge.)
Registration Policies
Discounts
Member rates are a benefit of UCAOA membership. To qualify, you must be a member at the time of registration. Membership will
need to be approved before you can register for the convention. Not sure? Email UCAOA to verify. If you are a member and see
non-member rates at checkout, please call our office at 877-698-2262 before completing your purchase. If you purchase
registration at the non-member rate and ask for a refund to reflect the member rate, you will be charged a $25 administration fee.
Student Registration
To qualify for a student discount, you must be a full-time student or resident. Proof of enrollment is required before registration
can be processed. Email proof of status to UCAOA at convention@ucaoa.org.
Spouse/Guest Registration
Spouse/Guests must pay for their own registration to attend educational sessions. If your spouse/guest would like to attend the
evening Exhibit Hall Receptions, they can purchase a pass at the time you register or on site. The Exhibit Hall Reception pass
includes beverage tickets.
Please note, to uphold the professional and educational standards of the meeting, children under 18 years of age are not permitted in
the exhibit hall or educational sessions. Attendee Guest Reception Passes are available for purchase for adults ages 18 and older.
Only paid registrants are able to attend the courses.
Schedule
The Conference schedule may be subject to change including topics, times and speakers if necessary.
Group Registrations
Register four or more individuals at the same time from the same organization and a 20 percent group discount will be applied to
the current registration fee. A registration form must be completed for each individual. The first four registrations must be
submitted simultaneously. Additional registrations (beyond four) will be registered with the group discount off current tuition prices.
Please contact UCAOA by email convention@ucaoa.org or phone 877-698-2262 for group registration.
Invoices & Check Payments
Please email convention@ucaoa.org or phone 877-698-2262 if you need an invoice.
Check payments sent in with a Registration Form can be mailed to:
Urgent Care Association of America
387 Shuman Blvd, Ste 235W
Naperville, IL 60563
If mailing a registration form, please note the tuition rate is determined by the postmarked date. Payment must accompany
register form. NO checks will be accepted after September 1, 2016.
Cancellation and Substitution Policy
Cancellation requests for registration must be received in writing at convention@ucaoa.org or faxed to 331-457-4539.
Membership fees are non-refundable.
Cancellations received by August 22, 2016, will receive a full refund, less a $100 processing fee.
Cancellation received August 23 through September 16, 2016, will be refunded 50 percent of original price.
NO Refunds will be issued after September 16, 2016. There are no exceptions to the cancellation policy.
Please allow four to six week for refunds to be processed via original payment method.
Cancelling your registration does not automatically cancel your hotel reservation(s); you must handle this separately.
Registrants unable to attend may send a substitute. If the substitute is not a member, the non -member fee will be charged.
Substitutions must be made in writing to convention@ucaoa.org.
CME Policy
The Urgent Care Association of America designates this live activity for a maximum of 12 AMA PRA Category 1
Credit(s)TM . Physicians should claim only the credit commensurate with the extent of their participation in the activity. UCAOA
recognizes the importance of continuing education (and especially urgent care-specific courses) for our physicians. To provide CME
to physicians, UCAOA must maintain our accreditation through the Accreditation Council for Continuing Medical Education. This
process requires significant fees and staff hours to ensure that stringent guidelines are followed by UCAOA as well as all vendors
and sponsors involved in our meetings in order to maintain our good accreditation standing.
Most other physician medical association conventions are funded or supported by corporations and/or pharmaceutical companies.
UCAOA is working to align itself with corporate partners to offset attendee costs and corporate support has been growing but is not
at a level yet to wholly underwrite the meeting’s expenses.
All physicians (MD/DO) must pay the CME fee. If you do not pay the fee and add it on after your original registration, you will be
charged an additional $50 administrative fee.
Designation Statement
The Urgent Care Association of America designates this live activity for a maximum of 12 AMA PRA Category 1
Credit(s)TM . Physicians should claim only the credit commensurate with the extent of their participation in the
activity.
Accreditation Statement
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for
Continuing Medical Education through the joint providership of the Urgent Care Association of America and the Urgent Care
College of Physicians. The Urgent Care Association of America is accredited by the ACCME to provide continuing medical education
for physicians.
Attendee Information
As a registered participant, I agree not to copy or permit to be copied, in any form or format, without the express written
permission of UCAOA, any of the contents of the UCAOA attendee roster. I also agree not to use the roster contents for any
commercial, marketing, promotional, or political purposes. No solicitation is permitted by anyone except by exhibitors within the
confinement of their booths.
Recording Policy
As a registered participant, I understand that I am prohibited from recording (audio and/or visual) any educational session content
unless I have obtained written permission in advance from UCAOA.
Photographic & Video Images Consent
Registration and attendance at, or participation in UCAOA events and other associated activities constitutes an agreement by the
registrant (faculty, attendee, exhibitor, etc.) to permit UCAOA to the use and distribution (both now and in the future) of the
registrant’s image and/or voice in photographs, videos, electronic reproductions, and audiotapes of such events and activities.
By initialing, I have read and acknowledge the above terms: Click here to enter text.