CONFERENCE REGISTRATION FORM
This form may be duplicated. (Required of all Participants)
(It is important to complete all information requested below.)


The 14th Annual
SOUTHWEST REGIONAL TRAUMA CONFERENCE
October 2-3, 2003 - Tucson Convention Center
Persons with a disability may request a reasonable accommodation, such as a sign language interpreter, by contacting Clint Brown at (520) 795-2170. Requests should be made as early as possible to allow time to arrange the accomodation.

*Name - include degrees and/or certifications (Example: Doe, RN, MS, MBA)     *Will appear on conference name badge

Last Name First Name Middle Initial Last Degree

Position: bullet CEP, EMT, Firefighter      bullet RN      bullet MD      bullet RT      bullet Other ___________________  (please specify)

*Title (Example: Nurse Manager, Director, Captain, etc.)

Social Security Number (Must have for CEU's)                                     RN License Number (Must have for CEU's)

*Organization

Organization Address

*City *State Zip Code

Home Address (not for publication) (Next year's brochure will be mailed to your home address. Brochures are not mailed to work addresses.)

City State Zip Code
(            )                                                     (            )
Area Code / Home Phone                          Area Code / Work Phone                         E-mail:   Home   /   Work   (please circle)

REGISTRATION FEES
Postmarked on/or before
September 1, 2003
Postmarked after
September 1, 2003
ONE DAY
BOTH DAYS
ONE DAY
BOTH DAYS
Physicians
$165.00
$240.00
$200.00
$275.00
Nurses, Residents, Others (e.g. Surgical Techs)
$135.00
$200.00
$170.00
$235.00
Respiratory Therapists
$125.00
$185.00
$160.00
$220.00
Paramedics and EMT's
$100.00
$150.00
$135.00
$185.00

NOTE: SATNET members can deduct $5.00 from their one day fee or $10 from their two day fee.

I WILL BE ATTENDING:
bullet Both Days
bullet October 2nd Only
bullet October 3rd Only

In order to keep registration fees at the lowest rate possible, a confirmation letter will not be mailed to you. If you have questions about your registration, please call.

NOTE: NONE OF THE REGISTRATION FEE IS CONSIDERED A TAX DEDUCTIBLE DONATION.

CANCELLATIONS AND REFUNDS: In order to receive a refund, cancellation requests must be made in writing and postmarked by September 1, 2003. No cancellations will be accepted by phone. Speakers are subject to change. In the unlikely event that this conference is cancelled, conference fees will be refunded to pre-registered participants.
Make checks payable to: SATNET
MAIL REGISTRATION FORM AND CHECK TO:
Clint Brown, Conference Director
Southern Arizona Trauma Network
PO Box 43818
Tucson, Arizona 85733-3818
bullet VISA              bullet MASTERCARD

Cardholders Name

Card Number

Expiration Date

Signature
SATNET Membership bullet YES, please enroll me as a member and I will add $10 to my registration amount. You will receive a free t-shirt or ball cap and free admission to the SATNET HAPPY HOUR on Thursday, October 2nd, at the Radisson Hotel City Center.