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2017Regional ConferenceRegistration Form
The Henry Hotel in Dearborn, Michigan, July17-18
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.
Organization:Click here to enter text. Professional Title (e.g. Owner, Medical Director):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/Phone: Click here to enter text.
Additional Information
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?☐Mailonly☐Email & Mail
If you have a disability and may require accommodations to fully participate, please describe.
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How did you hear about the UCAOA Regional Conference?(Select all that apply)
☐Website ☐Email ☐Mail☐Word of Mouth ☐ JUCM ☐ UCAccess ☐ Other _____
☐LinkedIn ☐Facebook ☐Twitter ☐Instagram
EXCLUSIVE DEAL: Enjoy the discounts of membership through the end of the year! This includes reduced fees on fall registration, free online resources, free copy of the UCAOA benchmarking report and more. If yes, choose member prices and someone will follow up with you regarding your membership package! / ☐Yes☐No
Regular Tuition Rates /
June 6th- July 14th Rates
Member / Non-member
UC Expertise for the Midwest Clinician (July 17 and 18) / ☐$600 / ☐$725
Today’s Essentials & Nuances in UC Management (July 17 and 18) / ☐$600 / ☐$725
Clinical Support & Super MA (July 18 only) / ☐$175 / ☐$250
Hands-on Lab (July 17 only) / ☐$350 / ☐$500
Hands-on Lab (July 17) & UC Expertise for the Midwest Clinician (July 18) / ☐$600 / ☐$725
Physicians MD/DO CME Fee / Physicians: Add the CME Fee to your registration / ☐$25
Total Amount: / Click here to enter text. /
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.
Student Registration
To qualify for a student discount of 30% off tuition, 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.
Spouse/Guest Registration
Spouse/Guests must pay for his/herown registration to attend the conference and any occurring sessions.Please note, to uphold the professional and educational standards of the meeting, children under 18 years of age are not permitted to attend.
Group Registrations
BOGO Member Offer: Buy 1 tuition at $500/$600, and get 1 FREE MA tuition (a $150/$175 value)!
Group Discount:Register four or more individualsat the same time from the same organization for discounted pricing. Please contact UCAOA by emailor phone 877-698-2262 for group registration and BOGO discount.
Invoices & Check Payments
Please emailor 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 July 3, 2017.
Cancellation and Substitution Policy
Cancellation requests for registration must be received in writing ator faxed to 331-457-4539.
Cancellations received by June 13, 2017, will receive a full refund, less a $100 processing fee.Cancellation received June 14 through July 1, 2017, will be refunded 50 percent oforiginal.NO Refundswill be issued after July 1, 2017. 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.Membership fees are non-refundable.
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. Registration fees are non-transferable to other UCAOA educational events and/or products.
CME Information
Designation Statement
The Urgent Care Association of America designates this live activity for a maximum of10 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.
CME Policy
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.
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.
I have read and acknowledge the aboveterms: Click here to enter text.
Signature