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
Urgent Care Fall Conference Registration Form
Sheraton New Orleans Hotel
September 24 -26, 2015
Attendee Name: ______________________________________________________________________________________________
Credentials:
MD
DO
PA
NP
RN
CPC
Other:____________________________
Professional Title (e.g. Owner, Medical Director): ___________________________________________________________________
Organization: ________________________________________________________________________________________________
Address: ____________________________________________________________________________________________________
City: ______________________________________________ State: ______________________ Zip/Postal Code: ______________
Mobile Phone: ________________________________ Attendee Email Address: _________________________________________
Email Address for Receipt: ______________________________________________________________________________________
Emergency Contact Name/Phone:_______________________________________________________________________________
Additional Information
Are you registering with a group of four or more?
Are you a decision maker related to new products/services for your company?
Would you like to opt out of receiving exhibitor emails?
Yes
Yes
Yes
No
No
No
If you have dietary restrictions please send an email to convention@ucaoa.org with details.
If you have a disability and may require accommodations to fully participate, please describe.
How did you hear about the UCAOA Fall Conference?
(select all that apply)
Web site
Email
Mail
Word of Mouth
UCAccess (UCAOA newsletter)
JUCM
Other ____________________________
Are you already a member of UCAOA?
Individual
Clinic Member
Joining Now
Individual $195
Physician $225
Student/Resident $75
Clinic Membership (Call for pricing)
Attendee Name: _____________________________________________________________________________________________
What Your Tuition Covers:
 Complimentary WiFi in meeting space and sleeping rooms
 Up to 12 CME (and/or UCMC) credit hours toward your ongoing professional development
 Meals and exhibit hall evening receptions
 More than 80 industry experts presenting hot topics in urgent care
 More than 100 exhibitors and over 7.5 hours to network with them

Complimentary download of all course materials for on-site use as well as after-conference access to all recorded sessions
(audio synched to PowerPoint slides)
EARLY
May 18- June 24
REGULAR
June 25 – Aug 20
Nonmember
Member
$ 995
Member
$ 900
Nonmember
$ 1,095
LATE
Aug 21 – Sept 17
Member
Nonmember
$ 1,000
$ 1,195
Main Conference (Sept 24 – 26)
$ 800
Group Discount:
If you are registering with a group of 4 or more, subtract 20% off tuition total
Physicians MD/DO CME Fee
Any physician claiming CME for this event, add the CME Fee to your registration
Total
Amount
- 20%
$ 50
Reservation required for the following courses due to limited availability
Hands-on Course(s)
Hands-on courses occur during the main conference. Space is limited. There is a
one-time $25 fee to reserve your spot. Please mark which course(s) you would like
to attend below.
$25
Courses
Course Dates
X
Hands-on Splinting and Casting
September 25 (All Day)
Hands-on Joint Injections
September 25 (Morning)
Hands-on Musculoskeletal Exam
September 25 (Afternoon)
Hands-on Advanced Suturing
September 26 (Morning)
Hands-on Basic Suturing
September 26 (Morning)
Attendees may purchase a pass for up to three guests for $50 each
to attend the Exhibit Hall Reception on September 24 & 25. If you are purchasing
Attendee Reception Guest Pass(es)
a pass to bring a guest, please be aware your guest must be at least 18
years old.
Guest 1
First/Last Name
$50
Guest 2
First/Last Name
$50
Guest 3
First/Last Name
$50
Membership - joining now to receive
member rates
Include dues amount here:
Total Amount of Payment:
Any registration after September 17 will have a $100 walk-in surcharge added to your tuition.
Payment:
Check Enclosed (Check No. ____________) (must be postmarked by 9/1)
Visa
MC
AMEX
Card No: _______________________________________Exp. Month/Year _________ / _________ CVV (security code): ________
Signature:_____________________________
Registrations processed and tuition rates set upon receipt of payment. See enclosed registration details. Please contact UCAOA if you have not received an email
confirmation within two business days.
Attendee Name: _____________________________________________________________________________________________
Please check off each box and sign below once you have read the following terms:
Attendee CME Compliance
UCAOA is accredited by the Accreditation Council of Continuing Medical Education to provide continuing medical education for
physicians. As an attendee of a UCAOA live event, I understand that I may not promote or disseminate anything in the classroom or
educational meeting space regarding products or services that I may offer. UCAOA educational activities must be free of commercial
bias for or against any product. If commercial products are discussed, the session must present objective information about those
products, based on generally accepted scientific evidence. Speakers must not engage in the marketing of their product(s) in any way
during the presentation. Exhibitors and vendors are limited to conducting business in assigned exhibit space. By checking the box I
agree to these terms.
I have read the Attendee CME Compliance
Consent for Use of Photographic & Video Images:
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.
I have read the Consent for Use of Photographic & Video Images
Cancellation Policy
1. Cancellations must be made in writing to convention@ucaoa.org or faxed to 331-457-5439.
2. Cancellations received by August 24, 2015 will be refunded via original payment method minus a $100 administration fee.
3. Cancellations received between August 25 and September 11, 2015 will be refunded 50% of original tuition via original payment
method.
4. After September 12, 2015, tuition is non-refundable.
5. Membership fees are non-refundable.
There are no exceptions to the cancellation policy.
I have read the Cancellation Policy Terms
I have read and acknowledge the above terms _____________________________________________________________________
Signature
Regarding the CME Fee:
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 conferences 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 September 17, you will be charged an
additional $50 administrative fee.
Group Discounts
For four or more people registering together, a 20% Group Discount will be applied to current tuition rates under the following
conditions (does not apply to membership dues):





A registration form must be completed for each attendee
The first four of the group must register simultaneously
Everyone in group must be from the same organization
Substitutions and course additions are allowed at later dates and will include the discount
Additional registrants (beyond 4) will be registered with group discount off current tuition
Late Registration Payments
Payment by check must be postmarked by September 1, 2015.
Tuition rate is based on postmark date, not date on check.
Registrations after September 17, 2015
Accepted on a walk-in basis on site, pending space is available. Payment is required at the time of walk-in. UCAOA cannot hold space
for late registrations. Walk-in registrations will be at late tuition pricing and are subject to an additional $100 walk-in surcharge
added to the tuition fee.
Substitution Policy
Conference registrants who are unable to attend are permitted to send a substitute. If the substitute is not a member of UCAOA, the
difference between the member and non-member tuition fee will be required. Substitutions must be made in writing to
convention@ucaoa.org or via fax to 331-457-5439.
What to Wear
Conference attire is business casual for all events. Meeting rooms are sometimes cool, so bring a sweater or jacket with you to class.
Continuing Medical Education
Designation Statement:
UCAOA designates the 2015 Fall Conference 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.