Annual Pay Later Form Annual Scientific Assembly Registration 2022 PAY LATER This form is for those who wish to PAY LATER. If you want to pay online by Paypal, please complete the form found here: https://www.msafp.org/register-and-pay-now/Registrant Name(Required) First Last Clinic (if applicable) Please Choose One:(Required) MD DO Medical Student NP Please click the box below if you are an AAFP Fellow with the designation 'FAAFP': FAAFP Please click the box below if you are a first-time attendee: First Time Attendee AAFP Member Number: T-shirt Size(Required)Please Choose Your SizeAdult SAdult MAdult LAdult XLAdult 2XLAdult 3XLAddress:(Required) Street Address City State / Province / Region ZIP / Postal Code Mobile Phone:MAFP use onlyYour Email:(Required) Spouse E-mail:Email will be added to the e-mail blast list to receive communications about the MAFP Annual Meeting. While in Destin, I will be staying...(Required) At the Sandestin Resort Off Property REGISTRATION FEES:Registration Fee(Required)PLEASE CHOOSE THE REGISTRATION FEE THAT APPLIES TO YOUMAFP Member - $525.00Life Member (must be 70 and retired) - $425.00NON-Member - $625.00Family Medicine Resident - $0.00Medical Student - $0.00NAMES FOR BADGES AND REGISTRATION LIST:Please list below any guests who will be attending with you who need a name badge. Name badges are REQUIRED FOR ADMITTANCE to MAFP events. **Please note that anyone age 18 and over who will attend any MAFP events must pay the Spouse/Guest fee.**Spouse/Adult Guest Registration Fee: Quantity Price: $250.00 Quantity Kids' Registration Quantity********This field is meant for children who are UNDER 18.******* Children 18 years or older who plan to attend any functions listed on this form must pay Guest Fee. Names and ages you list here will appear on the Registration List at the event. Price: $0.00 Quantity Spouse/Adult Guest Name + Name of Any Other Adult Guest(s):List any registered guests for whom you are paying the $200 guest fee. Please include any children 18 and over. Anyone you type here will receive a badge and their name will appear on the registration list.T-shirt Size(s) for Spouse/Adult Guest(s):A t-shirt is included in the Spouse/Adult Guest Registration Fee. Childrens' Name(s) and Age(s):The kids you list here will receive a badge and their names will appear on the Registration List. Extra T-shirts: QuantityA t-shirt is included with the Registration Fee and with the Spouse/Adult Guest Registration Fee. This blank is for any ADDITIONAL t-shirts you ordered. Price: $18.00 Quantity Extra T-shirts - Please List Desired Size(s):Available Sizes: Youth XS (2-4), Youth S (6-8), Youth M (10-12), Youth L (12-14), Adult S, Adult M, Adult L, Adult XL, Adult 2XL, Adult 3XL EVENTSKnowledge Self-Assessment Group Learning SessionTOPIC: BEHAVIORAL HEALTH. Saturday, July 16, from 2-5 pm at Baytowne Conference Center. Knowledge Self-Assessment (KSA) Study Groups give you credit for your maintenance of certification through the American Board of Family Medicine. Learners come together to complete the KSA by working through 60 core competency questions. Learners work together to assess, review, and decide the best answer as a group. ABFM awards 8 credits to diplomates who complete each session.IF ATTENDING, PLEASE CHOOSE ONEKSA MAFP Member Fee - $125.00KSA Non-Member Fee - $250.00Sunday 1-3 pm Session: "Transition Care Management: Managing the Hospital to Home Journey" Quantity(Required)Dr. E.G. "Nick" Ulmer will present this 2-hour session aimed at residents and new physicians. All registrants are welcome. There is no charge for this session, but please RSVP by indicating here. Price: $0.00 Quantity MAFP Royal Lawn Party Quantity(Required)Sunday, July 17, from 6 - 7:30 pm at the Marina Beach. Hear ye, hear ye! King Carlos and Queen Nalini invite members to join us Sunday evening for family-friendly food and activities. You can expect royal games and entertainment on the beach plus kayaking and paddleboarding for those who want to leave the shore. Wear your swimsuit and bring a towel for the water activities. Fee is included in registration. Price: $0.00 Quantity Spouse Bingo QuantityMonday, July 18, at 9 am at Baytowne Conf. Center. Spouses, enjoy the fun of a traditional BINGO game while making friends with other family members at the convention. We will award lots of prizes. Kids are welcome, but they will receive a ‘kid’s prize.’ Fee is included in registration. Price: $0.00 Quantity Golf Tournament QuantityMonday, July 19 at 2 pm at The Raven Golf Club. The Raven Golf Club is a natural wonder that presents drama and strategy on every tee. The format will be a 4-person scramble. Prizes will be awarded to first and second place teams. Other prizes determined by number of entries. The $130 cost includes greens fees, cart rental with GPS, range balls, and refreshments. Price: $130.00 Quantity Golf Tournament Player(s) and Handicap(s): Number Registered Adults Who WILL ATTEND Members Luncheon (Members Only) QuantityTuesday, July 19, at approximately 12 noon, Baytowne Conf. Center. Included in registration fee. Price: $0.00 Quantity EXTRA Tickets to Membership Luncheon for Non-Registrants Coming With You Quantity Price: $45.00 Quantity Syllabus Hard Copy QuantityOnline syllabus is available at no charge. Handouts will be available online and in the mobile app in July. Price: $100.00 Quantity MAFP FOUNDATION FUND RAISER ITEMSPurchase your items here , and they will be waiting for you at the Registration Desk!Split the Pot Fundraiser Ticket(s) QuantityDuring the MAFP 2022 Annual Scientific Assembly, the MAFP Foundation will hold the Family Medicine Strong Split the Pot fundraiser. Split the Pot tickets may be purchased for $100 per ticket anytime beginning Sunday until sales close Wednesday at 9 am. The winning ticket will be drawn in the Physician Marketplace on Wednesday during the morning coffee break. The lucky winner will take home ½ of the revenue from the tickets sold throughout the week. YOU DO NOT HAVE TO BE PRESENT TO WIN. Price: $100.00 Quantity Watercolor Print (Signed & Numbered) Quantity Price: $50.00 Quantity Images in Mississippi Medicine Book Quantity Price: $50.00 Quantity PAYMENTTotal CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ
