2024 WSPMA Annual Conference Registration Form Step 1 of 5 20% HiddenNext Steps: Install a Payment Add-OnTo accept payments on this form you will need to install one of our payment add-ons. To learn more about your payment add-on options, visit the following page (https://www.gravityforms.com/blog/payment-add-ons). Important: Delete this tip before you publish the form.RegistrationContact DetailsName(Required) Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Middle Last Name Badge(Required)Please enter your first name as you would like it to appear on your name badge In what city do you practice?(Required) Address(Required) 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 Phone(Required)Email(Required) Select work or home option belowIs email Home or Work(Required) Home Work I am currently registering as a(Required) Physician Resident/Fellow in WA State Program Speaker Other When selecting "Other", please enter Job TitleRegistration(Required) Lifetime Member $300 WSPMA member $350 First Year Practicing WSPMA/APMA Member $250 Resident/Fellow in WA State Program - Free Non-member $450 Other: When paying, please enter code that you have received from WSPMA Conference Attendee RosterPlease allow us to include you on the conference attendee roster (containing conference attendee names, titles, organizations, and email addresses), which will be available to conference attendees, as well as conference sponsors.By sharing your information in the roster, you will be able to: Connect with other conference attendees Easily share your contact information with new colleagues Receive relevant product and service information from conference sponsors supporting this event* *Sponsors have limited access to the attendee roster and may only use it to send two emails. If attendees are contacted by sponsors after the event, they always have the option to opt out of any promotional materials. Roster Inclusion Please include my contact information on the conference attendee roster Do NOT include my contact information on the conference attendee roster Hotel Registration WSPMA has reserved a room block at The Lodge at St. Edward State Park for the duration of the Conference. The Lodge has 84 beautiful rooms on the property and can accommodate most needs. The last day to reserve a room under our room block is on April 5, 2024. To register for your hotel room night(s), we have simplified the process for your convenience – you just need to fill out the following information now and then provide a credit card on your arrival day at The Lodge to pay for your room nights and incidentals. To view more information about the different room options, visit the following links: Class King Room, Lodge King Room, St. Edward King Room. Your Name(Required) Please select the nights and room type that you want to reserve. Check-in is at 4pm and Check-Out is at 11am. Thursday, May 2, 2024(Required) Classic King Room $289/night* Lodge King Room $309/night* St. Edward King Room $339/night* I do not need a room this night Please note below if you have special accommodations.Special Accommodations Friday, May 3, 2024(Required) Classic King Room $289/night* Lodge King Room $309/night* St. Edward King Room $339/night* I do not need a room this night Please note below if you have special accommodations.Special Accommodations Saturday, May 4, 2024(Required) Classic King Room $289/night* Lodge King Room $309/night* St. Edward King Room $339/night* I do not need a room this night Please note below if you have special accommodations.Special Accommodations *All room rates are quoted exclusive of applicable state, local and occupancy taxes. *A reduced $30/per night resort fee is charged at the end of your stay. The resort fee includes Nespresso coffee in-room, high-speed Wi-Fi, valet parking, free snacks and drinks in the library, lawn games, bike rentals, and state park fee. Activities RegistrationWe are looking forward to getting together in-person again and are planning a few fun activities in addition to our daily lectures. These activities are free! Please let us know which activities you would like to attend, as this will help us in planning each activity. Thursday, May 2, 2024 - Welcome Activity from 7:00pm - 9:00pm(Required) Yes, I will attend Yes, I will attend and would like to bring a guest (price is free) No, I will not attend Friday, May 3, 2024 - Social Hour from 5:30pm - 6:30pm(Required) Yes, I will attend Yes, I will attend and would like to bring a guest (price is free) No, I will not attend Friday, May 3 2024 – Dinner & Entertainment from 6:30pm – 9:30pm(Required) Yes, I will attend Friday dinner & entertainment Yes, I will attend and would like to bring a guest (guest dinner is $50 and will be added to your registration cost at checkout) No, I will not attend Friday dinner & entertainment Dietary Restrictions and Additional ServicesPlease let us know if you have any dietary restrictions, mobility limitations, or other special accommodation needs. WSPMA will do its best to accommodate dietary restrictions, but we cannot guarantee that all special diets can be accommodated. Special Requests(Required) I require vegetarian meals I require vegan meals I require gluten-free meals I have no requests Other If choosing other (please list food allergies and/or other ADA request below).Cancellation PolicyConsent(Required) I agree to the cancellation policyWhat is the cancellation/refund policy for the Annual Conference registration fee: All cancellations must be submitted via email to WSPMA at info@wspma.org on or before April 5, 2024. If a cancellation is received on or before April 5, 2024, the registration fee will be refunded minus a $50 processing fee. NO REFUNDS for cancellation of the Annual Conference registration fee will be made after April 5, 2024. However, substitute attendees are permitted, as long as WSPMA has received that information by April 26, 2024. No refunds/reimbursements will be made by WSPMA for outside lodging, airfare or any other expense related to attending the conference. Payment DetailsTotal Coupon If provided, please enter code that you have received from WSPMA.Credit Card Cardholder Name Card Details CommentsThis field is for validation purposes and should be left unchanged. Upcoming Events APMA 2024 Coding and Clinical Education SeminarAPMA 2024 Coding and Clinical Education SeminarDate Apr 27 - 28, 2024Time All Day EventVenue WebinarOrganizer APMAMore Info WSPMA's Annual ConferenceWSPMA's Annual ConferenceDate May 2 - 4, 2024Time All Day EventVenue The Lodge at St. Edward State ParkOrganizer WSPMAMore Info Our Corporate Sponsor
APMA 2024 Coding and Clinical Education SeminarAPMA 2024 Coding and Clinical Education SeminarDate Apr 27 - 28, 2024Time All Day EventVenue WebinarOrganizer APMAMore Info
WSPMA's Annual ConferenceWSPMA's Annual ConferenceDate May 2 - 4, 2024Time All Day EventVenue The Lodge at St. Edward State ParkOrganizer WSPMAMore Info
