SMSNA/ISSM 2012 World Meeting on Sexual Medicine
Meeting Registration Form
August 26 – 30, 2012
Register early for discounted rates. Registration Fees are subject to change.
Thank you for your interest in attending the upcoming World Meeting on Sexual Medicine. The online registration is now closed; however, on-site registration will be available at the meeting. |
| |
|
|
|
|
| |
|
|
|
|
| |
|
|
|
|
| *A full listing of SMSNA/ISSM 2012 World Meeting on Sexual Medicine attendees will be provided in your registration packet. SMSNA and ISSM advises registrants provide their office address rather than their home address. |
| |
| |
|
|
|
|
| |
| |
MEETING REGISTRATION
*All registrations include 1 ticket to the Welcome Reception. |
| Registration Categories |
Early Discounted
(before 4/1/12) |
Early Discounted
(before 8/1/12) |
Regular Fees
(on or after 8/1/12) |
| |
|
|
|
|
Sunday Only Sessions
-- A special discount is offered to those attending Sunday only. If you are only attending on Sunday, August 26, please check this box to receive the discount. († elligible for discount) |
| |
|
|
|
SMS/ISSM Member
Health Professional/MD/PhD
† |
$545 |
$695 |
$845 |
SMS/ISSM Non-Member
Health Professional/MD/PhD
(May not be employed by industry; see industry information below) † |
$745 |
$895 |
$1045 |
ISSM/SMSNA Member*
Resident/Fellow/Nurse/PA
† |
$325 |
$425 |
$525 |
ISSM/SMSNA Non-Member*
Resident/Fellow/Nurse/PA
† |
$425 |
$525 |
$625 |
| Students**
† |
$250 |
$325 |
$395 |
*A letter of the chairman of the department is compulsory.
**A copy of your valid student ID card should be sent to the registration office for validation and you are required to have your original student ID card on-site. |
| |
|
|
|
| Industy Employee - Company is Exhibiting
|
$200 |
$200 |
$200 |
| Industry Employee - Company is NOT Exhibiting
|
$1500 |
$1750 |
$2000 |
| |
|
|
|
Spouse/Guest
|
# people
x |
$130 |
$130 |
$155 |
| (Spouse/Guest Registration includes 1 Welcome Reception ticket and
1 Chicago Architecture Boat Tour) |
| |
|
|
|
|
| ADDITIONAL TICKETS |
| Additional Tickets for non-registered guest(s) to the Welcome Reception. |
|
| Welcome Reception
|
# of tickets
at $65 per ticket |
|
| |
|
|
| Additional Optional Event Tickets for non-registered guest(s) and registered attendees for the Boat Tour. |
|
| Chicago Architecture Boat Tour |
# of tickets
at $65 per ticket |
|
| |
|
|
| |
| |
|
|
|
|
| |
OTHER EVENTS (Included in registration fee)
Please let us know if you will attend the functions: |
| |
Welcome Reception – Sunday, August 26, 2012
The Sexual Medicine Society of North America and International Society for Sexual Medicine welcome attendees to the 2012 World Meeting on Sexual Medicine. Members can visit with exhibitors and connect with fellow members all while enjoying delicious drinks and Hors d’oeuvres.
One ticket is included in your attendee registration fee.
If bringing a guest, you must either register your guest for the meeting, which includes a ticket to the Welcome Reception, or you must purchase a Welcome Reception ticket separately.
|
| |
| The following 3 morning sessions are being held concurrently. You may only choose one session to attend. |
Non-Physician Practitioners – Sunday, August 26, 2012
One ticket is included in your attendee registration fee.
|
| |
Mental Health Professional Symposium – Sunday, August 26, 2012
One ticket is included in your attendee registration fee.
|
| |
Surgery Symposium – Sunday, August 26, 2012
One ticket is included in your attendee registration fee.
|
| |
| The following 3 afternoon sessions are being held concurrently. You may only choose one session to attend. |
Women’s Sexual Health Symposium, in association with ISSWSH – Sunday, August 26, 2012
One ticket is included in your attendee registration fee.
|
| |
Special Language Symposium – Spanish/Portuguese – Sunday, August 26, 2012
One ticket is included in your attendee registration fee.
|
| |
Special Language Symposium – Chinese – Sunday, August 26, 2012
One ticket is included in your attendee registration fee.
|
| |
PAYMENT INFORMATION
The SMSNA/ISSM requires payment for registration fees and full payment of optional activities by check or credit card. |
| |
Special Needs
For accommodations on the basis of disability or special dietary needs, please call +1-847-517-7225. |
| |
Registration Cancellation & Refund Policy
Registration refund requests must be submitted in writing to the SMSNA Executive Office by 8/1/12. All refund requests will be subject to a $100 processing fee. No refunds will be made after 8/1/12. |