Test Fall Conference 2022 Registration With Online Payment This form is for those who wish to register now and pay online with Paypal or credit card. If you want to register now and pay later, go to msafp.org/fall-pay-later-2Registrant Name(Required) First Last 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 Clinic (if applicable) Please click the box below if you are a first-time attendee: First Time Attendee AAFP Member Number: Address:(Required) Street Address City State / Province / Region ZIP / Postal Code Mobile Phone:MAFP use onlyYour Email:(Required) First time Attendee? Yes No While at the conference, I will be staying overnight at:(Required) The Inn at Ole Miss Off Property Spouse/Guest Name for Name Badge: Spouse E-mail:Email will be added to the e-mail blast list to receive communications about the Fall Conference. REGISTRATION FEES:Registration Fee(Required)These fees reflect a 3% added fee to accommodate our Paypal fees. Registration fees will rise $50 each on October 14, 2022. Cancellation Policy: Refunds, minus a $50 cancellation fee, will be made upon request in writing to the MAFP office, if received by October 14. After October 14, no refunds will be granted.PLEASE CHOOSE THE REGISTRATION FEE THAT APPLIES TO YOUMAFP Member - $361.00NON Member - $464.00Family Medicine Resident - $0.00Medical Student - $0.00Spouse RegistrationIf your spouse or guest will attend any MAFP events during the conference, you must register them by paying the Spouse Registration Fee.PLEASE CHOOSE THE REGISTRATION FEE THAT APPLIES TO YOUSpouse/Guest Fee - MAFP Member - $50.00Spouse/Guest Fee - NON Member - $100.00NO SPOUSE/GUESTWelcome Reception: Quantity6:30 pm Friday at The Inn at Ole Miss. Please let us know the number of adults in your party who will attend. This event is included in member and spouse registration fee. Price: $0.00 Quantity Spouse Tour of Rowan Oak: QuantitySaturday at 9 am. Transportation will be provided from The Inn at Ole Miss. Rowan Oak is home to Oxford’s Nobel-Prize-winning author William Faulkner. It was built in 1848 and occupied by Faulkner from 1930 until his death in 1962. Each person will pay their own $5 entry fee. Price: $0.00 Quantity Oxford Trolley Tour: QuantitySaturday from 3-4 pm. Will pick up and drop off at The Inn at Ole Miss. A 1-hour trolley tour with a local historian provides a trip through history, visiting points of interest on the University of Mississippi campus and around the city. PLEASE RESERVE YOUR SPACE ON THE TROLLEY BY INDICATING A NUMBER HERE. Price: $15.50 Quantity OTHER ITEMSItems you order here will be waiting for you at the registration desk.Syllabus Hard Copy QuantityOnline syllabus is available at no charge. Handouts will be available online. Price: $100.00 Quantity MAFP Crew-Neck Sweatshirt - $30.00 each Quantity'MAFP' in big letters with 'Mississippi Academy of Family Physicians' written underneath. Text is navy on the white and grey items and white on the navy blue items. Price: $30.00 Quantity Sweatshirt Size & Color100% cotton crew-neck sweatshirt available in white, grey and navy blue. Sizes range from Adult Small to 3XL. Please specify your size and color preference here. MAFP T-shirt - $18 each Quantity'MAFP' in big letters with 'Mississippi Academy of Family Physicians' written underneath. Text is navy on the white and grey items and white on the navy blue items. Price: $18.00 Quantity T-shirt Size & Color100% cotton Gildan crew-neck t-shirt available in white, grey and navy blue. Sizes range from Adult Small to 3XL. Please specify your size and color preference here. MAFP FOUNDATION FUND RAISER ITEMSPurchase your items here , and they will be waiting for you at the Registration Desk!Watercolor Print (Signed & Numbered) Quantity(Special price for Fall Conference attendees) Price: $50.00 Quantity Images in Mississippi Medicine Book Quantity Price: $50.00 Quantity PAYMENTTotal Payment MethodPayPal Checkout American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Security Code Call MAFP at (601) 853-3302 with any questions.CommentsThis field is for validation purposes and should be left unchanged. Δ
