20th Annual Southwestern Conference on Medicine
April 28 – May 1, 2011
JW MarriottStarrPass Resort and Spa, Tucson, Arizona
26 Credit Hours Category 1A / AMA PRA Category 1
Note: Additional 4 Credit Hours available with BonusWorkshops
Please complete this form and fax to(520) 299-4609 or email it to . You may also mail it, with payment to:
Tucson Osteopathic Medical Foundation
Southwestern Conference on Medicine
3182 N. Swan Road
Tucson, AZ 85712
Registration Information (please print,attach a business card or type information):
Please indicate the appropriate title by checking the space provided:
( )DO ( )MD ( )PA ( )NP ( )RN ( ) OtherAOA Number______
Name:
Specialty:
Address 1:
Address 2:
City/State/Zip:
Business Phone: Fax: Email:
Preferred Name on Badge:
Special Needs / Additional Comments:
Please note that your address will be published in the Conference materials provided to attendees.
Bonus Workshops (please select if attending):
____ I will attend: “Joint Injection Workshop”
Saturday, April 30, 2011 from 1:30 – 3:30 pm (2 Credits Available)
____I will attend: “OMT Workshop”
Saturday, April 30, 2011 from 3:30 – 5:30 pm(2 Credits Available)
or
____I will attend: “Spanish for Healthcare Providers”
Saturday, April 30, 2011 from 1:30 – 5:30 pm (4 Credits Available)
Meal Functions(please indicate which meal functions you will and will not attend):
Note: Each Conference participant may bring one guest to the Friday Night Reception. All other meal functions are for registered participants only.
Thursday Breakfast:Yes No
Thursday Luncheon: Yes No
Friday Breakfast:YesNo
Friday Luncheon with Exhibitors: YesNo
Friday Reception:YesNo
Guest (one per Conference participant for Friday Reception only):YesNo
Saturday Breakfast:YesNo
Sunday Breakfast:YesNo
_____Please check here for special dietary needs.
Course Materials:
A detailed agenda plus course materials on a CD will be available at sign in. Additionally,
the presentations will be available for download after April 1, 2011 at
Pricing and Payment (please check one):
Active Physicians:
$500** Early Tuition (before 4/1/11)
$550** Regular Tuition (from 4/2/11 - 4/27/11)
$595** On-Site Tuition
Retired & Semi-Retired Physicians, Physician Assistants and Nurse Practitioners:
$400** Early Tuition (before 4/1/11)
$450** Regular Tuition (from 4/2/11 - 4/27/11)
$495** On-Site Tuition
Residents and Fellows:
$50**Early, Regular and On-Site Tuition
**26 hours of CME credit, online course materials and CD copy, daily breakfasts, Thursday and
Friday lunches, 4 hours CME credit for Bonus Workshops and the Friday night
Reception (with one guest per registrant) are included in the program tuition fee.
I will be paying by check.
Please make checks payable to Tucson Osteopathic Medical Foundation and mail to:
Southwestern Conference on Medicine
3182 N. Swan Road
Tucson, AZ 85712
(520) 299-4545 or (800) 201-8663
FAX (520) 299-4609
I will be paying by Credit Card.
Credit Card Type: Visa Mastercard American Express
Card Number:Exp. Date:
Name on Card:
Billing Address:_
Authorized Signature:
(Please note that credit card charges will appear as Tucson Osteopathic Medical Foundation)
Cancellation Policy:
All requests for refunds must be in writing. Requests postmarked by April 22, 2011 will entitle registrant
to a full refund less a $60 processing fee. Refund requests will not be available after this date.
For more information on this and other CME events, please visit our website or call (520)299-4545.
**Please note: the above registration does not include hotel reservations. Please contact the hotel directly if you need to make a room reservation.
Hotel Information:
JW MarriottStarrPass Resort & Spa
3800 W. Starr Pass Boulevard, Tucson, Arizona85745
A special rate of $199.00 single or double occupancy, plus tax is being offered to Southwestern Conference participants. Rooms may be reserved at this special rate until April 6, 2011, or until the Foundation’s room block is filled. Please visit the following website to reserve your hotel room: You may also call the JW Marriott Starr Pass directly at
1-800-266-9432and indicate that you are with the Southwestern Conference group.