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American Delirium Society
2020 Annual Meeting Registration
First Name
*
Last Name
*
Badge Name
Credentials (If none, please enter "N/A")
*
Affiliation (Organization)
*
Title
Email Address
*
Mobile Phone Number
*
Address 1
*
Address 2
City
*
State
Zip
*
Country
Registration Type:
*
(ADS Member) Physician
(ADS Non-Member) Physician
(ADS Member) Non-Physician
(ADS Non-Member) Non-Physician
(ADS Member) Resident/Fellow
(ADS Non-Member) Resident/Fellow
(ADS Member) Student
(ADS Non-Member) Student
Check All Events You Wish to Attend as a (Member) Physician:
*
Pre-Conference ($200)
2 - Day Conference ($500)
Outdoor Concert at The Rathskeller (Monday) ($40)
Check All Events You Wish to Attend as a (Non-Member) Physician:
*
Pre-Conference ($300.00)
2 - Day Conference ($650.00)
Outdoor Concert at the Rathskeller ($40.00)
Check All Events You Wish to Attend as a (Member) Non-Physician:
*
Pre-Conference ($200.00)
2 - Day Conference ($450.00)
Outdoor Concert at the Rathskeller ($40.00)
Check All Events You Wish to Attend as a (Non-Member) Non-Physician:
*
Pre-Conference ($300.00)
2 - Day Conference ($600.00)
Outdoor Concert at the Rathskeller ($40.00)
Check All Events You Wish to Attend as a (Member) Resident/Fellow:
*
Pre-Conference ($100.00)
2 - Day Conference ($250.00)
Outdoor Concert at the Rathskeller ($40.00)
Check All Events You Wish to Attend as a (Non-Member) Resident/Fellow:
*
Pre-Conference ($100.00)
2 - Day Conference ($350.00)
Outdoor Concert at the Rathskeller ($40.00)
Check All Events You Wish to Attend as a (Member) Student:
*
Pre-Conference ($50.00)
2 - Day Conference ($50.00)
Outdoor Concert at the Rathskeller ($40.00)
Check All Events You Wish to Attend as a (Non-Member) Student:
*
Pre-Conference ($50.00)
2 - Day Conference ($150.00)
Outdoor Concert at the Rathskeller ($40.00)
ADS Apparel Options
(Deadline May 1, 2020):
ADS Fun Run (Monday 6AM) with Running T-Shirt ($35.00)
Running T-Shirt Only ($20.00)
Polo Only ($25.00)
Fun Run Shirt Size:
*
XS
S
M
L
XL
XXL
XXXL
Running Shirt Size:
*
XS
S
M
L
XL
XXL
XXXL
Polo Shirt Size:
*
XS
S
M
L
XL
XXL
XXXL
Please select ALL meals you plan to attend:
*
SUNDAY - Breakfast
SUNDAY - Lunch
MONDAY - Breakfast
MONDAY - Lunch
TUESDAY - Breakfast
N/A - I am NOT attending any meals.
Please list any dietary needs
(if no dietary needs, list "N/A"):
*
Are you a presenting abstract author?
*
Yes
No
Please select the appropriate payment method:
*
Credit Card - if paying by credit card, proceed through PayPal
Check - if paying by check, make payable to ADS and send to the address below
Current Total:
0.00
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American Delirium Society (ADS)
6737 W Washington St, Ste 4210
Milwaukee, Wisconsin 53214
(414) 488-3912 | info@americandeliriumsociety.org
www.americandeliriumsociety.org