Program Directors Workshop Registration

Hands-On Workshops

Tuesday, March 17 & Wednesday, March 18 | 7:30 am – 5:00 pm

OMT Boot Camp

Written Test Taking Board ReviewBoot Camp

Type 1 Diabetes in the Primary Care Setting

Convention registration not included

(Please select date and time you wish to attend)

*Includes ticket to the President’s Reception.

Program Directors WorkshopResidency Program Coordinator Workshop

$525 $225

Tuesday Wednesday

3:00 – 7:00 pm3:00 – 7:00 pm

Wednesday 8:00 am – 12:00 pm

SOLD OUTWednesday, 11:30 am – 6:00 pm

PhysicianResident

$225 $100

PhysicianResidentStudent

$225 $100 $75

Convention Registration Through February 7 After February 7

$ 850 $1,250 $ 350 $ 375 $ 250 $ 150 No Fee

$1,000 $1,400 $ 400 $ 450 $ 300 $ 150 No Fee

Member*Nonmember*Retired Member*First Year in Practice*Resident MemberStudent MemberState Society Executive Director

Joint Injection $275

$375

$200

$200

$200

$200

TOTAL $

Wednesday, 8:00 am – 12:00 pm

Wednesday, 8:00 am – 5:00 pm

Friday, 2:00 – 4:30 pm

Friday, 2:00 – 4:30 pm

Friday, 2:00 – 4:30 pm

Saturday, 1:00 – 2:30 pm

MARCH 18 – 22, 2020 | HILTON NEW ORLEANS RIVERSIDE | NEW ORLEANS, LOUISIANA

ACOFP 57TH ANNUALCONVENTION & SCIENTIFIC SEMINARS

The Convention officially begins on Thursday, March 19, but you can also register for extra credit CME programs and hands-on workshops beginning on Tuesday, March 17.

IUD Insertion and Primary Care Gynecological Procedures

Integration of OMT and Injections forCommon Orthopedic Concerns

Dermatology and Basic Wound Care

Common Braces and Splints in Primary Care

Introduction to Ultrasound for the Family Physician

AdditionalRegistration

$150 $ 50 No Fee

$175 $ 80 No Fee

Spouse / Guest*Child (Ages 6-18)* Child(Ages 5 or younger)

Auxiliary Fundraiser Sponsorship

FRIDAY, 8:00 – 10:00 AM

Auxiliary Family Breakfast

TOTAL $

Physicians, spouse/guests and children ages 6 and older receive a ticket to the President’s Reception with their paid registrations. State Society Executive Directors, residents and osteopathic medical students, their spouse/guests and children who would like to attend the President’s Reception must purchase tickets for the event.

Registration Information

Payment Information

AOA/ACOFP ID#: ______________________________ NPI#: ________________________________ Preferred Email Address: _____________________________

Full Name: ___________________________________________________________________________ Preferred Daytime Phone: _______________________________

Name as it Should Appear on Badge: ___________________________________________________ Preferred Number: Home Work Cell

Street Address: ___________________________________________________________________________________ Preferred Address: Home Office

City: _____________________________________________________________ State:_____________________ Zip:____________________ Fax:_____________________

Dietary Restrictions or Accessibility _______________________________________________________________________________________________________________

Needs: Spouse / Guest Name(s): _______________________________________________________ Child Name(s): ________________________________________

Spouse / Guest Email(s): ____________________________________________________________________________________________________________________________

The ACOFP Auxiliary will hold its annual fundraising event during ACOFP ‘20. Show your support by sponsoring the Auxiliary’s fundraising efforts. All sponsors making a donation by February 1 will have their names and sponsorship level recognized during ACOFP ‘20.

(limited to 125 participants)Students & Residents Tickets: $50 x ______ = $ ______Member Tickets: $100 x ______ = $ ______Would you like to make a donation to fund studentsattending the program? $______

Diamond ($5,000) Sapphire ($1,500) Other $__________

All attendees and their families are invited to attend.

Saturday, 6:15 PM

Adults: $100 x ______ = $______

FRIDAY, 12:00 – 1:30 PM

Additional President’s Reception Tickets

Lunch Session: Women, Medicine and Leadership

_______________ + _________________ = ________________

Platinum ($1,000) Gold ($750)

Silver ($500) Bronze ($250)

adults attending children attending total # attending

ThroughFebruary 7

Check enclosed, please make payable to “ACOFP” Total Remittance: $ _________________________

MC Visa Amex Discover

Credit Card Number: ___________________________________________________________________________ Expiration Date: _______________________________

Print Name on Card: __________________________________________________________________ Signature: ________________________________________________

AfterFebruary 7

ACOFP ‘20, 330 E. Algonquin Road, Suite 1, Arlington Heights, IL 60005

847.228.9755

Questions? Call 847.952.5100

Register online at: www.acofp.org/ACOFP20

*Includes ticket to the President’s Reception.

Seating 1, 8:00 – 9:00 am

Seating 2, 9:00 – 10:00 am

State Society Executive Directors: $100 x ______ = $______

Residents, students & children under 18:$50 x ______ = $______