WSAUA 2019 Mont Reg Form

Advance
Registration Form

Monterey 2019

Advance registration rates end October 12

We are so happy you can join us!
Please complete this form - you can choose payment type on the next page

Please select your category *

AUA Physician

Non-AUA Physician

Resident/Fellow/Med Student

APP/Allied Health Professional

Please select your category *

AUA Physician

Non-AUA Physician

Resident/Fellow/Med Student

APP/Allied Health Professional

Please select registration package *

Resident - $150

Fellow - $150

Medical Student - $150

Please select registration package *

Advance Practice Provider - $445

Physician Assistant - $445

Advance Practice Nurse - $445

Nurse Practitioner / Reg. Nurse - $445

Office/Practice Manager - $445

Medical Sciences Liaison - $445

Please select registration package *

Non-AUA Physicians - $1045

Please select registration package
*

Western Section Member - $645	Western Section Senior - $545
AUA Member, Other Section - $655

Verification letter or email (INFO@WSAUA.ORG) from Department Chairman required.

Subject to verification of company affiliation and title.

Registration Package Details

WsAUA / AUA Physician Package

Includes badge, materials and admittance to all daily educational programs/sessions and related meals. Also includes these special sessions and activities:

-Saturday pre-meeting: Powered-UP Urology Practice Success Clinic (must rsvp below)

-Health Policy Forum & Lunch

-Exam Review Prep Courses

-Round Table Program & Brunch

-The LAB - networking lounge & hospitality (breakfast/breaks) and activities

-SOCIAL EVENTS: welcome reception, happy hour networking events, and final night gala.

click here to see preliminary schedule

Non-AUA Physician Package
Includes everything in the AUA Package above.

Resident / Fellow Package*
Includes everything in the AUA Package above plus the Resident's Program & Lunch. Resident/Fellows may also bring a spouse/guest at a discounted rate as our way of welcoming you into the Western Section. Your spouse/guest will receive the full spouse/guest package.

*Verification letter or email (INFO@WSAUA.ORG) from Department Chairman required.

APP-PA-Allied Health Professional Package
Includes everything in the AUA Package except the final night gala on Wednesday for which tickets may be purchased separately. Also includes the APP-Allied Health Program. This category includes APPs, Nurse Practitioners, Physician Assistants, Practice Administrators, and Office Managers, etc.

Spouse/Guest Package
Includes badge for admittance to the spouse/guest hospitality room (Sun-Weds), exhibits and evening social events including the welcome reception and the final night gala. Spouse Hospitality will feature a deluxe continental breakfast Sunday to Wednesday. Does not include CME.

Children: Families are welcome at the Western Section! A registered spouse/guest may bring their children at no extra charge to the spouse/guest hospitality room for breakfast. Children under age 10 may attend the evening social events at no charge. Junior tickets (age 10-20) are also available. Children under 16 are not allowed in the exhibit areas or sessions.

Please provide the information below: (Please type as you wish your name to appear in print)

First Name *

Middle

Last Name *

First Name for Badge *

AUA ID# (to expedite CME credits) 🛈

Please indicate AUA Section: *

Addendum (e.g., M.D., D.O.)

Organization / Company

Title

Address 1 *

City *

State/Province/Region *

Zip/Postal Code *

Country *

Email Address: * 🛈

Optional 2nd Email Address: 🛈

Office/Home Phone *

Mobile Phone (for on-site use) 🛈

Where are you planning to stay? *

Portola Hotel

Marriott (no group block)

Other Other

RSVP for Saturday pre-meeting clinic, 2pm to 6pm
Powered-UP! Urology Practice Success Clinic - more info *

Attending

Not attending

Add Spouse and/or Guest Registration:

Add Spouse / Guest - $225	Add 1 Additional Guest - $225
Add Spouse / Guest of Resident/Fellow/Med Student - $150

Spouse / Guest Name(s) for Badge: *

Optional: Spouse/guest Email Address: (for info about relevant programs)

If planning to bring children, how many under age 10?

How many over age 10?

Sports/Tour Interest List: We are considering the following activities. Please indicate if you are interested. We will notify you if/when these events are happening.

Optional - Additional Tickets for Guests:
Please indicate quantity in box below: 🛈

	Sunday Health Policy Forum Luncheon, $55
	Sunday President's Welcoming Reception Adult, $85
	Sunday President's Welcoming Reception Junior, $45
	Wednesday Western Section Night Gala Adult, $125
	Wednesday Western Section Night Gala Junior, $65
	Thursday Round Table Program & Brunch Ticket, $55

General Comments:

Admin Code

Current Total:

$0.00

Cancellation Policy: You may cancel your registration up to 21 days prior to the meeting (on or before October 12, 2019) without penalty. You will receive a full refund promptly. Cancellations for any reason received after October 12, 2019 cannot be refunded. However, registration is transferable to a friend or associate, or if you decide not to use it we will credit it to a future meeting minus a $100 processing fee. No shows cannot be refunded.

Assistance: Please let us or the resort know if you are physically disabled and have special requirements. Send a description of your needs or call us at 714-550-9155.

Consent to Use of Photographic Images: Registration and attendance at, or participation in, WSAUA meetings and other activities constitutes an agreement by the registrant to WSAUA to use and distribution (both now and in the future) of the registrant or attendee’s image or voice in photographs, videotapes, electronic reproductions and audiotapes of such events and activities.

NEED HELP or HAVE CHANGES: Please call or email us at 714-550-9155 (info@wsaua.org) for assistance. Thank you.

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