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)

Guest/Spouse Full Name:

The 2024 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