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Wilderness Medical Society - jackson hole reg

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Wilderness Medical Society - jackson hole reg
HOW TO REGISTER
By fax:
Download a registration form online at
wms.org and fax to 800-967-7494
By phone: 719-572-1372
By mail:
Wilderness Medical Society
5390 N. Academy, Ste. 310
Colorado Springs, CO 80918
EARLY BIRD SPECIAL: REGISTER FOR THE WINTER
CONFERENCE BEFORE NOVEMBER 14, 2003 AND RECEIVE
A 10% DISCOUNT!
Please print or type. Form may be photocopied.
WMS Member Number: _________________________________
First:__________________MI___Last: _____________________
Degree(s): ____________________________________________
Address: _____________________________________________
____________________________________________________
City: ________________________________________________
State/Province:_____________ Zip/Postal Code: _____________
Country: _____________________________________________
E-mail: ______________________________________________
Tel ( ) _____________________ Fax ( ) _________________
Specialty: ____________________________________________
We want you to enjoy this WMS program. Please let us know of
any special requirements you have: ________________________
____________________________________________________
CONFERENCE REGISTRATION
WMS members pay the lowest rate.
Rate
Member
Non-Member
Doctoral
$495
$595
Non-Doctoral
$295
$395
Student Resident
$195
(Student registration must be accompanied by proof of student status)
SIG Member
$25
Special Team Rate: 10% discount for groups of 3 or more
registering at the same time.
"
Snow King Resort Reservations for lodging only
(800) 522-5464. Jackson Hole Reservations for combination
lodging and airfare (800) 443-6931, ext. 3032.
Activities (800) 522-5464 ext. 7128
SUMMARY OF PAYMENT
#
Conference Registration
(includes 1 banquet ticket)
$___________
#
Special Team Rate Registration (3 or more)
or Early Bird Discount
-10% =
$___________
#
Winter Survival
$100 =
$___________
#
Yurt Trip
$450 =
$___________
#
Map & Compass
$75 =
$___________
#
Wilderness Cook-off
$10 =
$___________
#
High-functioning Teams
$40 =
$___________
#
GPS in the Wilderness
$75=
$___________
#
Sunday OR
#
Monday (please check one)
#
Avalanche Recognition
$60 =
$___________
#
Surviving A Wilderness Emergency $125 =
$___________
TOTAL
$___________
#
Check enclosed. Make checks (payable in U.S. funds)
payable to: Wilderness Medical Society or
#
Charge to:
#
#
Acct.#:______________________________Exp. Date: ________
Signature: ____________________________________________
Note if your registration must be canceled, a refund less $100 will be
allowed if requested in writing by January 10, 2004. We regret that
refunds will not be allowed after January 10, 2004.
ACCREDITATION
The Wilderness Medical Society (WMS) is accredited by the Accreditation Council for
Continuing Medical Education to sponsor continuing medical education for physicians.
Physician Credit: The WMS designates this educational activity for a maximum of 25 hours
of credit in category 1 towards the AMA Physician's Recognition Award. Each physician
should claim only those hours of credit that he or she actually spends in the educational
activity.
ACEP: The Winter Wilderness Medicine Conference is approved by the American College of
Emergency Physicians for 25 hours of ACEP Category 1 Credit.
AAFP: The Winter Wilderness Medicine Conference has been reviewed and is acceptable for
up to 25 hours prescribed credit by the AAFP.
Please contact the WMS office for additional accreditation information.
Disclosure of Faculty's Commercial Relationship(s): Faculty members for the Winter
Wilderness Medicine Conference are expected to disclose, at the beginning of their
presentation(s), any economic or other personal interests that create, or may be perceived as
creating a conflict related to the material discussed. This policy is intended to make
participants aware of the faculty's interests, so they may form their own judgments about such
material. Full disclosure of the faculty's relationships is included in the course syllabus.
To Join WMS visit our website at
www.wms.org and join online!
WINTER CONFERENCE 2004
PROGRAM
REGISTRATION FORM





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