39th Annual Meeting Registration Form

First Name *

Last Name *

Designation (MD, BSc etc.)

WVS Member? *

Yes

Institution/Company *

Phone Number

Email Address *

Registration Type: *

WVS Active Member ($425.00)

Non-Member Physician ($475.00)

Non-MD Allied Health Professional ($325.00)

Resident or Fellow ($200.00)

Medical Student (FREE)

Virtual Attendee WITH CME ($175.00)

Virtual Attendee NO CME (FREE)

If registering as a non-member physician or allied healthcare professional , please indicate the current WVS member who invited you to join the meeting, as per the society bylaws: *

Do you wish to register family members or guests? *

Yes

Guest registration includes WVS banquet, WVS family dinner and breakfasts. Please enter the number of guests you wish to register below:

	Spouse/Guest of Member, Physician or Sponsor ($300.00)
	Spouse/Guest of Resident, Fellow or Medical Student ($200.00)
	Children 12 and Under ($75.00)

Spouse/Guest(s) Full Name:

Child(ren) Full Name(s):

Do you, or any of your registered guests, have any dietary restrictions or allergies?

Yes

Please provide more information:

I understand that by registering for this event, and signing below, I hereby grant Western Vascular Society and Surgical Conference Solutions the absolute and irrevocable right and permission, in respect of the photographs and/or video taken of me, to use, re-use, publish, and re-publish the same in whole or in part, individually or in conjunction with other photographs or video, and in conjunction with any printed matter, or electronic matter, in any and all media now or hereafter known, and for educational and/or marketing purposes. *

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Questions?

Please email admin@surgicalcs.com

or call Heather Roderick at (360) 420-6906