Registration Fees		Before Oct. 1	After Oct. 1		CME Hours Available
Physicians	(3 days)	$ 395.00	$ 485.00		Friday	8.0
	(2 days)	$ 365.00	$ 425.00		Saturday	8.0
	(1 day)	$ 190.00	$ 225.00		Sunday	6.75
NP’s & PA’s, PT’s	(3 days)	$ 250.00	$ 275.00		Fri, Sat, Sun	22.75
	(2 days)	$ 175.00	$ 225.00
	(1 day)	$ 100.00	$ 125.00
RN’s	(3 days)	$ 200.00	$ 250.00
	(2 days)	$ 150.00	$ 175.00
	(1 day)	$ 75.00	$ 100.00
Chiropractic Physicians	(Sunday Only)	$ 150.00	$ 175.00
ATC’s, Coaches, PTA’s	(3 days)	$ 125.00	$ 135.00
	(2 days)	$ 90.00	$ 125.00
	(1 day)	$ 65.00	$ 80.00
Residents, Medical Students, Student Trainers		$ 20.00*	$ 30.00*	^* same fee 1 day -3 days

MAKE CHECKS PAYABLE TO:

Family Medicine Foundation of WV

QUESTIONS: (304) 765-7839

Fax: (304) 765-3838

E-mail: fam.med.foundation@citynet.net

CANCELLATION ~ No Penalties ~

To encourage pre-registration which helps you avoid waiting in line and helps our volunteer staff, 100% refund if requested by the day following the conference – November 17^th, 2008

RETURN CME REGISTRATION FORM TO:

The Family Medicine Foundation of WV, P O Box 359, Flatwoods, WV 26621

22^nd ANNUAL FAMILY MEDICINE WEEKEND & SPORTS MEDICINE CONFERENCE, November 14, 15, & 16, 2008

Name _____________________________________ Day(s) Attending (Fri, Sat, Sun) _________________

(Please Print)

Profession (MD, DO, DC, PA, RN, NP, PT, ATC etc) _________________

Mailing Address ___________________________________________ E-mail ______________________

City, State, Zip ____________________________________ Phone ________________ Fax ___________

Name of Spouse/Guest ________________________ RSVP Friday buffet __________

number attending LIMITED TO 200

Your Spouse/Guest is welcome to visit Exhibit Hall and other events. Nametags are required. Print name above.

…………………………………………………………………………………………………………..………..

Office Use Only:

Amount Paid ______________ Check # _______________ Date ______________ Hours ______________ Owes _________