ASIA Title
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2012 Annual Meeting Registration



ATTENDEE INFORMATION:
ASIA Member? (check box)
 
First Name:
 
Last Name:
 
Designation:
Other:
 
Institution:
 
Street Address:
 
City:
 
State:
Zip:
Country:
(if not U.S.A.)
 
Telephone:
 
Fax:
 
E-Mail:
 

Please check if applicable:   Speaker    Poster Presenter   Moderator

Check here for special needs:   Accessibility    Dietary

Registration Selections

Pre-Course - Wednesday, April 18, 2012:
“Gait Assessment and Treatment: New Approaches and Advanced Technologies”,
presented by local host Craig Hospital
  Through
04/02/2012 		On-site
after 4/02/2012
Pre-Course (limited number) $125 $175
NOT attending Pre-Course $0  

 

ASIA Meeting (Thursday, April 19 - Saturday, April 21):
  Through
04/02/2012 		On-site
after 4/02/2012
ASIA Member $425 $475
Non-Member $500 $550
Student, Fellow, Resident (with written verification from department chair) $200 $250
Single Day Admission (Member) $200 N/A
Single Day Admission (Non-Member) $250 N/A
Single Day Admission (Student, Fellow, Resident) $100 N/A
Exempt from Registration Fee. $0  
 

Add Extras:

  
Caregiver/Personal Attendant (includes all food and beverage & Welcome Reception) $100 $100
Guest (Welcome Reception only) $50 $50
 
Check if Vendor:    



NAME BADGE INFORMATION:
Name on name badge:

(e.g., Jane A. Doe, M.D. or Mr. John Smith)
 What's this?
City, State or Country
on name badge:

(e.g., Atlanta, GA or Toronto, Canada)
  
Guest's First Name:

(if applicable)
  
Guest's Last Name: 

(if applicable)
  
Caregiver/Personal Attendant's
First Name:

(if applicable)
  
Caregiver/Personal Attendant's Last Name:

(if applicable)
  

Pay by:

 Credit Card
Check
  

I am registering/paying for someone else.

Your Name:

Security Question:

To combat spammers, we are incorporating the following mathematical question. Please enter a numeric value to answer the question.

What is 4 + 4?

Please be sure to review the above information for accuracy BEFORE clicking Submit.

Refund and Cancellation Policy:
Registration cancellations WILL NOT be accepted by phone.
Cancellations MUST be in writing.

  • A $75 fee will be assessed and the balance refunded for cancellations postmarked through MARCH 23, 2012.
  • NO REQUESTS FOR REFUNDS WILL BE ACCEPTED AFTER MARCH 23, 2012.
  • Refunds will not be issued until after the meeting.
  • Partial or full fees that have been forfeited cannot be applied to subsequent years.

Image author Hogs555, Denver Skyline from City Park, licensed under Creative commons Attribution-Share Alike 3.0 Unported license