Associationfor Research in Otolaryngology

40thAnnualMidWinter Meeting

February 11-15, 2017

Baltimore Marriott Waterfront
Baltimore, Maryland

REGISTRATION FORM

I. PERSONALINFORMATION PleasePrintClearly--Abbreviate ifNecessary

First-TimeAttendee:YesNo

Last(Family)NameFirstName

Dept.Institution

StreetAddress

CityState/ProvincePostalCodeCountry

PhoneFax

Emailaddress

II. MEETINGREGISTRATION

OnorBeforeAfterDecember 12, 2016

December 12,2016andOnSite

[ ]Member $250.00 $300.00

[ ] NHCA Member $250.00 $300.00 [ ]spAROMember(Student/Trainee) $120.00 $145.00 [ ]Non-Member $450.00 $540.00 [ ]Non-Member(Student/Trainee)* $220.00 $265.00

RegistrationFee$

*SignatureREQUIRED:ProgramDirector/Dept.Chair

PrintNameInstitution

AdditionalFees

[ ]$30.00PrintedAbstractBook / AbstractBook / $_

$______

RegistrationFeeTOTAL

[ ] Ifyouneedspecialassistance,pleasecheckbox

[ ] Checkthisboxifyouwouldlikeassistancewithcaptioning,assistivelisteningdevices,and otheraccessibilityservicesforthosewithhearingimpairment/deafnessattheAROmeeting.

SpecialNotetotheDisabled: AROwishestotakestepstoensurethatnoindividual withadisability isexcluded, deniedservices,segregated orotherwise treateddifferently thanotherindividuals becauseoftheabsenceofauxiliary aidsorservices. IfyoushouldneedanyauxiliaryaidsorservicesidentifiedintheAmericanswithDisabilitiesAct,or anyassistanceinregisteringforthismeeting,pleasecontacttheAROMeetingsDepartmentat(856)423-0041,orbyfax at(856)423-3420.YoumaywritetoAROMeetingsDepartment,19MantuaRoad,Mt.Royal,NJ08061.

Registrant’sName:

III.MEMBERSHIPDUES

[ ]New(MemberYear:January 2017-December2017)
-ACVmustaccompanythisform.
-*Associatemembershipapplicantsmustprovideproofoftraining. / [ ] Regular($120)
[ ]Associate($50)*
[ ]Renew (MemberYear:January 2017-December 2017;unlessmembershipislapsed)
-Lapsedmembersmustincludethe$25.00reactivationfeeaspartoftotalcosts. / [ ]Regular($120)
[ ]Associate($50)

ThisapplicationmustbesignedbytwoRegularMembersofAROingoodstanding.Insigning,thesponsoragreesto supporttheapplicant’smembershipandtoserveastheapplicant’sreferenceifrequested.IfAROmembersarenot availableinyourhomecountry,pleasecontactAROExecutiveOfficeat+1856-423-0041oremail formoreassistance.

1.Sponsor(print)Signature

Address

2.Sponsor(print) Address

Signature

ApplicantSignature:Date:

$______

Membership FeeTOTAL

IV.METHODOFPAYMENTFORREGISTRATION FEESANDMEMBERSHIPDUES

Note:Registrationand/orMembershipfeeswillappearas“AROCC”.

Ifyoufaxyourregistrationform,DONOTsendtheoriginalformbymail. Doingsomayresultinduplicatechargesto yourcreditcard!

IfPaying byCheck:Makecheckpayable toARO,inU.S.Dollars andissuedbyaU.S.Correspondent Bank.Each registrantisresponsibleforanyandallbankcharges.Checkwithyourlocalbankbeforeprocessingpayment. A$50.00 processingfeewillbechargedforallreturnedchecks.Pleasefilloutaseparatecheckformembership fees,and makepayabletoARO.

Registration/Cancellation Policy: Your registration will be confirmed in writing within two weeks of receipt of payment. If confirmation is not received by that time, please call (856) 423-0041 opt. 3. If you must cancel your registration, all requests must be received in writing to ARO Registration, , no later than Friday,January13,2017.Allfeespaidwillberefundedminusa$25.00processing fee. Therewillbenorefunds aftertheFriday, January 13, 2017deadline.

METHODOFPAYMENT

[ ] CHECK(U.S.CurrencydrawnonU.S.BankpayabletoARORegistration)

[ ] VISA[ ] MASTERCARD[ ] AMERICANEXPRESS

RegistrationFees$______Membership Dues$______

TOTALAMOUNT$

CreditCard#______

Exp.Date: / CVV: ______

NameonCard

AuthorizedSignature

AROreservestherighttochargethecorrectamountregistration sum ifdifferentfrom theabove noted.

2017 ARO MWMPRE-MEETINGQUESTIONNAIRE

(PleaseReturnwithRegistrationForm)

*ThefollowinginformationisneededforreportingpurposesforARO’sNIHfundinggrant.

Yourparticipationinthissurveyisgreatlyappreciated.

1.Gender: / oMale / oFemale
2.Age: / 018-21
051-60 / 022-30
061-65 / 031-40
065+ / 041-50

3.Ethnicity(selectone):oHispanicorLatinooNotHispanicorLatino

4.Race(selectallthatapply):0AmericanIndianorAlaskaNative0Asian0BlackorAfricanAmerican

0NativeHawaiianorOtherPacificIslander0HispanicorLatino0Caucasian

5.Areyoudisabled?oYesoNo

6. Doyouconsideryourselfprimarilya(chooseonlyone):

oAdministrator / oClinician / oClinician-scientist / oClinician-investigator
oPostDoc / oResearcher / oResident / oStudent
oTeacher / oTechnician / oOther

7. Degree:

oMDoMD,PhDoPhDoOther

8. Myprimaryareas ofinterestare(selectoneormore):

oAuditory(CNS)oAuditory(InnerEar/Neural)oAuditory(Outer/MiddleEar)

oAuditoryNeuroscienceoBiochemistryoChemicalSenses(Smell/Taste)

oDevelopmentalBiologyoGeneticsoImmunology oLaryngologyoOtology/Neurotology oPathology

oPharmacologyoPsychophysicsoSpeech/Voice oVestibular

oOther:

9. If you are not an ARO member, what are the major reasons for not joining ARO?

oFinancial burdenoFew obvious benefits of membership

oAlready a member of many societiesoHave only just begun attending ARO meetings

oDo not often attend ARO MeetingsoForgot to renew

oIt takes too long to both register and joinoOther (please specify)______

______

10. Of the past five ARO meetings how many have you attended?

o0o 1o2

o3o4o5

11. Would be interested in becoming a mentor? o Yes oNo

Pleaseaddyourcommentsandsuggestions

PleasereturncompletedRegistrationFormwithpaymentto:

ARORegistration,19MantuaRoad,Mt.Royal,NJ 08061 orreturnviafaxto(856)423-3420.

Ifyouchoosetofaxyourregistration, DONOTsendtheoriginalformbymail.