AMIA 1998 Annual Symposium
Advance Online Registration Form

AMIA must receive this form by the deadline of October 23, 1998. Please use a separate form for each registration.

Registration

First name
Last name
Degree
Title/Position
Department
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Phone
Fax
E-mail

Badge Information

This is how your badge will read. If information is the same as above, skip this section.

Name/Degree
Organization
City/State/Country

Your full registration fee includes the cost of the AMIA'98 Proceedings. Please indicate your choice of format: CD-ROM or Print. Additional copies may be ordered below.

AMIA'98 Fees

  Advance

(by 10/23)

 On-Site
Full Registration      
AMIA/CPRI Member $490 $565
Nonmember $735 $790
Student Registration
(please include proof of student status*) 		     
AMIA Preprofessional Member* $ 120 $180
Nonmember Preprofessional* $165 $225
AMIA Postdoctoral Member* $220 $280
Nonmember Postdoctoral* $285 $345
Author Registration      
Member $360 $410
Nonmember $605 $655
Single-Day Registration
(please check day or days) 		     
Sun., Nov. 8 Mon., Nov 9 Tues. Nov 10 Wed. Nov 11
All Registrants $245 $270
Exhibits-Only Registration      
All Registrants $50 $ 50
Computer--based Patient Record Institute Conference (Nov 6)      
CPRI Member/Org. Rep $0 $0
Nonmember $170 $180
Tutorial Registration
(Fee is per tutorial for each half-day tutorial; to qualify for discount on second half of two-part tutorials, you must register for both parts. See the Program Preview and Advance Registration for a guide to tutorials.) 		     
AMIA/CPRI Member $210 $260
Nonmember $285 $335
AMIA Student* $175 $205
Nonmember Student* $225 $255
Part II of Two-Part Tutorials $135 $135
Please select appropriate tutorials (only one tutorial per time period).      

Tutorials

Sat, Nov 7 - A.M.

Tutorials

Sat, Nov 7 - P.M.

Tutorials

Sun, Nov 8 - A.M.

Tutorials

Sun, Nov 8 - P.M.
Workshop Registration
(included in registration fee)		      

Workshops

Sat, Nov 7 - P.M.

Workshops

Sun, Nov 8 - P.M.

    
Events      
Do you plan to attend the Welcome Reception?
Do you plan to attend the First Timers Breakfast?
Do you plan to attend the FPPC Conference?
Do you plan to attend the General Membership Meeting?
Do you plan to attend AMIA's Dessert Reception?
Publications (Your full registration fee includes the cost of the AMIA'98 Proceedings. Additional copies may be ordered below).
AMIA'98 Proceedings (CD-ROM): Quantity: x $70 ea.
AMIA'98 Proceedings (Print): Quantity: x $70 ea.
Total Enclosed or To Be Charged: $

Payment Information

Payment must be in U.S. dollars payable through a U.S. bank.

Make checks payable to AMIA.

Check enclosed in the amount of: $
Please charge my credit card in the amount of: $
VISA MasterCard American Express Purchase Order

Card number

Exp. Date

Cardholder name (if different from registrant)

Submitting Your Advance Registration

AMIA will not process registrations received without payment. Registrations and payment must arrive in the AMIA office by October 23,1998. Registrations received after October 23 will be processed at on-site registration rates. Please direct questions to:

American Medical Informatics Association
Telephone: 301-657-1291
E-mail: michelle@amia.org

Additional Information

This is my first AMIA Annual Symposium.
I need special assistance. (If you require special accommodations to participate fully in the symposium, please check here and enclose a description of your needs.)
Please do not include my name on mailing lists given to other organizations.

Please double check the information you provided on this form before submitting.
Last revised: May 11, 2000