KSA Bootcamp 2020

Registrant Name

First Last

Please Choose One*

MD
DO
NP

Are you an AAFP Fellow?*

Yes
No

AAFP Number*

ABFM Number

Clinic Name:

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Cell*

(For MAFP use only)

E-mail*

Clinic FAX:

How do you plan to attend the meeting?*

Do you plan to stay at the Jackson Hilton Hotel?*

Yes
No

Payment

CANCELLATION POLICY: Payment is due November 30. Refunds will be made upon written request to the MAFP office, minus a $50 administrative fee, if received by November 30. After November 30, no refunds will be granted.

I will attend (please choose one)*

I will attend all 3 sessions. - $400.00
I will attend two sessions. -- $300.00
I will attend one session. -- $150.00

Choose Your Session(s):

Select All
DEPRESSION: 8-10:30 am
HYPERTENSION: 11 am - 1:30 pm
PALLIATIVE CARE: 2 - 4:30 pm

Payment Choice*

Check (mailed to MAFP)
Credit Card

If paying by credit card, please call the MAFP after submitting this form (using the number on the screen after submitting) to give us your credit card. We are not able to accept credit card numbers online or by e-mail.

Total

$ 0.00

Name

This field is for validation purposes and should be left unchanged.

Details About the KSA, Speakers & Schedule

Payment