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Registration Form
First Name
*
Last Name
*
Designation (MD, DO, BSc etc)
Institution/Company
*
Email Address
*
Registration Type:
*
SCVSS Active Member ($350.00)
SCVSS Retired Member ($175.00)
Non-Member Physician ($450.00)
Non-MD Allied Health Professional ($175.00)
Resident or Fellow ($175.00)
Medical Student (FREE)
Guest/Spouse ($100.00)
Payment Type:
*
Visa
Mastercard
Amex
Expiration
*
Card number last 4 digits:
*
Guest/Spouse Full Name:
The 2025 Presidential Banquet is intended to be an adult-only event. There will be a separate supervised kids party taking place at the same time. Please enter the number of tickets you like to purchase for our concurrent children's event ($50 per child):
Child Ticket ($50 each)
Would you like to add a donation to the Robert J. Hye Fund? If so, please indicate amount:
Questions?
Please email
admin@surgicalcs.com
or call Heather Roderick at (360) 420-6906