Neurology Residents - USF Social Marketing Conference



|REGISTRATION FORM |

24th Social Marketing Conference & Training Academy

June 15-18, 2016 – Sheraton Sand Key Resort – Clearwater Beach, FL

FORM FIELDS ENABLED – PLEASE TYPE

|First Name: |      |MI: |      |Last Name: |      |

|Degrees/Credentials: |      |Organization: |      |

|Street Address: |      |

|City / State / Zip: |      |Birth Date (mm/dd): |      |

|Daytime Phone: |      |Fax: |      |Cell: |      |

|E-Mail (Required): |      |Gender: | Female Male |

|Do you want your e-mail to appear on the participant list? | Yes No |CHES License #: |       |

|Professional Profile: | Certified Health Ed. Spec. (CHES) | CPH:       Other:       |

|How did you hear about this course? | Website E-Mail Colleague Postcard Other:       |

|Will you attend Friday’s reception? | Yes No |

|Registration Fee |

|OPTION |Early Bird |Regular |Full Time Student* |

| |(Thru 05/20/16) |(5/21/16 on) | |

|Full Conference (Wednesday through Saturday) | $530 | $630 | $280 |

|Training Academy Only (Wednesday & Thursday) | $355 | $405 | $205 |

|Main Conference Only (Friday & Saturday) | $355 | $405 | $205 |

|Single Day – Wed Thursday Friday Saturday | $205 | $205 | $105 |

|Guest Ticket for Reception (free to registrant) | $35 | $35 | $35 |

*Students must submit a valid photo ID copy or a letter/e-mail from their department head to qualify for the discount. This can be faxed to 813-974-5172 or e-mailed to brose@health.usf.edu. Only FULL-TIME students qualify for the discount.

|PAYMENT METHOD |

| Check (payable to USF HPCC) |Amount: |$      |

| Credit Card: AmEx MasterCard Visa Discover |Credit Card Exp. Date: |      |

|Credit Card Number: |      |CCV / Security Code: |      |

|Name on Credit Card: |      |Signature: | |

| Purchase Order – You must e-mail brose@health.usf.edu for permission to pay via PO. |

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