Chapter Officers Conference (COC) Registration Form
REGISTRATION DEADLINE: June 16, 2008
OR
print this form & send completed with payment
by June 16, 2008 to:
amsa®
P.O. Box 2291
Merrifield, VA 22116-2291
Name __________________________ AMSA ID (if known) ________
Address (summer) _____________________________________
___________________________________________________
Phone __________________ E-mail ______________________
I attend: Medical International Premedical School
School & Location ____________________________________
Grad. Year ______________________ Gender: male female
I PLAN TO ARRIVE AND DEPART:
arrival date & time ___________ departure date & time ___________
PREFERENCE OF ROOMMATES:
There will be four people (same gender) in a room. You may request someone
from your region, specific individuals, etc. _______________________________________
LOBBY DAY REGISTRATION:
To Be Announced
FOOD PREFERENCE: vegetarian
non-vegetarian
Other, please specify: ______________________________
OTHER SPECIAL NEEDS: ________________________________
(Wheelchair access, hearing disability, etc.)
REGISTRATION FEES: Please check one
| Medical Chapter | $ 150.00 | |
| Premedical Chapter Premed chapter officers wishing to attend are REQUIRED to contact AMSA's Premedical Trustee for prior approval and details. |
$ 150.00 | |
| International Chapter International chapter officers wishing to attend are REQUIRED to contact AMSA's International Trustee for prior approval and details. |
$ 150.00 |
check
or money order enclosed for registration fee checked above
charge
the $150 registration fee to my:
MasterCard VISA
Card No. ____________________________ Exp. Date ______
Signature ______________________________ Date ________
REFUNDS: are issued only if cancellations are received prior to July 3, 2008.
COC REGISTRATION FEES COVER:
Hotel accommodations will be made for you (four attendees of the same gender to a room) if you return your registration form BEFORE the deadline date of June 16, 2008. Accommodations will be available for Thursday, Friday and Saturday nights, but you MUST specify your arrival and departure dates and times on the registration form above.
Conference materials and meals. Conference materials will be handed out at the on-site registration table on Friday, July 18. Conference meals include: Friday: breakfast, lunch and dinner; and Saturday: breakfast and lunch.
If you have any questions, please e-mail or call AMSA's membership services at (800) 767-2266, Monday-Friday, 9:00 am-5:00 pm, EST.