2022 Annual Meeting Registration 2022 Annual Meeting Registration Skamania Lodge Stevenson, WA June 10-12 Contact Information Name* First Last Credentials (MD, DO, etc) Preferred First Name for Badge (If different than above) Practice/Group Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands PhoneEmail* Optional - Food Preference Vegetarian Vegan Gluten free Please list any food allergies Will you attend the Friday night reception? (Included with registration) Yes No Number of Adults for Friday Night ReceptionPlease enter a number from 0 to 15.Number of Children under 13 for Friday Night ReceptionPlease enter a number from 0 to 15.Will you attend the Saturday night dinner? (Included with registration) Yes No WSPS requires that all attendees and their families (except non-eligible children) provide proof of vaccination, or a negative PCR test administered 24-48 hours prior to the conference. You can upload you and your family’s vaccination cards here, or select the option to show a negative COVID test at the conference. Please select from the following:* I will upload my Vaccination Card I will show results of a negative COVID test adminstered 24 hours prior Vaccination Card upload Drop files here or Select files Accepted file types: jpg, gif, pnh, pff, Max. file size: 256 MB. Number of Adults for Saturday Night DinnerPlease enter a number from 0 to 15.Number of Children under 13 for Saturday Night DinnerPlease enter a number from 0 to 15.Meeting Registration WSPS Member - $450.00 Physician Non-member - $550.00 ARNP/PA Member - No Charge - $0.00 ARNP/PA Non-Member - $365.00 Resident - No charge - $0.00 Optional - Adult Guest Meal TicketsAges 13 and older Price: $100.00 Quantity: Optional - Pay My 2022 WSPS Membership DuesWSPS Dues for 2022: $300 Yes, I would like to pay my dues Optional - Pay My 2022 WSPS Membership Dues Price: TOTAL $0.00 Coupon CREDIT CARD American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Security Code Cardholder Name CANCELLATION POLICY: We must receive written notification of your cancellation. A $75 processing fee will be deducted from the registration refund. No refunds after June 1, 2022. INQUIRIES Contact the WSPS Office at 206-956-3642 or email admin@wasocietyofplasticsurgeons.org. Δ
