FAX
800.967.7494
PHONE
719.572.1372
MAIL
Wilderness Medical Society
5390 N. Academy Blvd., Ste. 310
Colorado Springs, CO 80918
ONLINE
WMS Member Number: ________________________________
Name: ______________________________________________
First
MI
Last
Degree(s): ___________________________________________
Address: ____________________________________________
___________________________________________________
City
State/Providence
Zip/Postal
___________________________________________________
Country
E-mail: _____________________________________________
Tel: ( ) ________________________________________
Fax: ( ) ________________________________________
Specialty: ___________________________________________
We want you to enjoy this WMS program. Please let us know of
any special requirements you have:
___________________________________________________
___________________________________________________
___________________________________________________
Yes, I would like to plan for one or more the Uniquely
Alaska activities: Iditarod Package, Flight-Seeing Over
Denali, or Wildlife Cruise! Send me the sign-up information
right away.
Alyeska Resort Reservations call 907.754.2111 or
toll free 1.800.880.3880 to reserve your room.
Conference Registration
WMS members pay the lowest rate. If you are not a member,
join online at www.wms.org to receive your member discount!
Rate
Member
Non-Member
Doctoral
$495
$595
Non-Doctoral/Resident*
$295
$395
Student*
$195
$295
*Validation of student or resident status required with registration.
Summary of Payment
Conference Registration Fee
(see categories above)
$_______________
Early Bird Discount Register by 11/14/03
-10% $_______________
Special Team Rate (3 or more)
-10% $_______________
(or -20% if both apply. Discounts applicable to Conference Registration Fee only)
Optional Workshops
Sunday-
Cold-Weather Survival
$ 60
$_______________
Igloo Building (only)
$ 25
$_______________
Igloo Building and Overnight
$ 50
$_______________
Monday-
Cold-Weather Tactical Medicine $ 95
$_______________
Ice Climbing
$125
$_______________
Igloo Overnight stay
$ 50
$_______________
Tuesday-
Ice Climbing
$125
$_______________
Cold-Weather Survival
$ 60
$_______________
Igloo Overnight stay
$ 50
$_______________
Wednesday-Avalanche Rescue
$ 85
$_______________
Optional Post-Conference Workshops
Cold-Water Helicopter Survival Course
$175
$_______________
Glacier Travel and Crevasse Rescue
$295
$_______________
Additional Banquet Ticket(s)
(registration includes 1 banquet ticket)
_____x $ 40
$_______________
Total
$_______________
Check enclosed. Make checks (payable in U.S. funds) payable to:
Wilderness Medical Society
or Charge to:
Visa MasterCard
Acct.#: ______________________________________________
Exp. Date: ___________________________________________
Signature: ____________________________________________
Note: if your registration must be cancelled, a refund less $100 will be allowed if requested
in writing by February 10, 2004. We regret that refunds will not be allowed after that date.
How to Register
EARLY BIRD SPECIAL
Register before November 15, 2003
and receive a 10% discount!
EARLY BIRD SPECIAL
Register before November 15, 2003
and receive a 10% discount!
Please print or type.
Form may be photocopied.
Visit www.wms.org
and click on "Conferences" for an Early
Bird registration form to download and
fax to 800-967-7494.
Wilderness Medical Society
International Conference on
Cold-Weather Medicine
Alyeska (Anchorage), Alaska · March 611, 2004
To
join
WMS visit our website at
www
.wms.or
g
and join online!
