The Wilderness Medical Society
6
th
Annual Student Round Table & International Summer Conference
July 31- August 6, 2004
Snowmass At Aspen, Colorado
S
TUDENT
I
NTEREST
G
ROUP
C
OMPLIMENTARY
R
OUND
T
ABLE
&
C
ONFERENCE
R
EGISTRATION
F
ORM
Print and then fill out this form to enroll one person for a complimentary registration to the 2004 WMS Annual
Student Round Table & Summer Conference. Please type or print legibly.
Name of University/Student Group_____________________________________________________
First__________________________Mi______Last_________________________________________
Address____________________________________________________________________________
City______________________________________________State/Province_____________________
Zip/Postal Code_________________ Country_______________________
E-mail______________________________________________Phone__________________________
1. Please Note: Only 1 complimentary registration per SIG. Additional SIG members may register for the
conference at the WMS Student rate of $195 through the WMS website (
www.wms.org
). You will be
automatically registered for the Round Table when you sign up as a student through the WMS website.
2. Optional conference workshops are available at the student's expense. If you wish to register for the
optional workshops, please refer to the WMS website and the conference brochure to reserve your spot.
Please return this form by July 15, 2004 to:
Jennifer Mariano
Wilderness
Medical
Society
5390 N. Academy Blvd., Ste. 310
Colorado Springs, CO 80918
Phone: 719-5721372
Fax: 800-967-7494
E-mail: jenjmariano@hotmail.com
