2015 AzGS 27th Annual Fall Symposium

The Future of Geriatrics: A Person-Centered Paradigm

Friday-Saturday, October 30-31, 2015 in Phoenix, AZ

EARLY REGISTRATION (by September 30th) LATE REGISTRATION (after September 30th)

AzGS Member: AzGS Member:

Physician (MD/DO/EdD/PsyD/PhD/NP) $300 Physician (MD/DO/EdD/PsyD/PhD/NP) $325

Other Allied Professional $225 Other Allied Professional $250

Full-time Geriatric Fellow/ Full-time Geriatric Fellow/

Resident/Healthcare Student $50 Resident/Healthcare Student $75

Non-Member: Non-Member:

Physician (MD/DO/EdD/PsyD/PhD/NP) $350 Physician (MD/DO/EdD/PsyD/PhD/NP) $375

Other Allied Professional $275 Other Allied Professional $300

Full-time Geriatric Fellow/ Full-time Geriatric Fellow/

Resident/Healthcare Student $75 Resident/Healthcare Student $100

Special 5% discount when registering five (5) or more employees from the same company

I would also like to join AzGS as an individual member for the remainder of 2015. My new membership rate of: $80 - Doctoral Level - OR $72 - Allied Professional will enable me to register for the AzGS 2015 Fall conference at the discounted AzGS member rate.
Add dues to total below…

Type of Credit Wanted: CME Nursing Social Work NCIA (LTC/AL) Case Mgt

Personal Information (List preferred degree(s) to be shown on nametag and roster) Fill out completely.

First Name / Middle Initial / Last Name / Degree (s) / Medical License # (for specific CEUs)
Company Name (to be shown on roster)
Company Mailing Address (to be shown on roster)
City / State / Zip
Home Mailing Address (to be shown on roster if no business address provided)
City / State / Zip
Daytime Phone / Preferred Email Address (to be shown on roster)

Method of Payment

Enclosed is payment by check payable to Arizona Geriatrics Society

Please charge my credit card: AmEx MasterCard Visa

$
Credit Card Number / Total Amount to Charge
Name on Card / Security Code / Expiration Date

Send registration form (and check if applicable) to:

Arizona Geriatrics Society

500 N. 3rd Street, ASU NHI-1, Phoenix, AZ 85004

Register online at www.ArizonaGeriatrics.org

Call the office (602) 265-0211 Fax (602) 274-8086

Email to:

A $25 handling fee will be charged for cancellations requested by September 30th; no refunds will be issued after that date.