SLEEP 2014 REGISTRATION FORM
Section I - Registration Information
(Please print clearly)
Section II – General Session Registration
Section II Total:
$____________
*Registrants must have
AASM, SRS, or AAST
individual membership status
at the time of registration.
May 29, 2014, is the pre-
registration deadline; an
additional $25 fee applied to
on-site registrants.
Registration Type
on or before 4/16
4/17-5/19
q
AASM/SRS/Dual Individual Member*
$300
$375
q
Nonmember
$525
$600
q
Resident/Postdoctoral Member
$180
$180
q
Resident/Postdoctoral Nonmember - complete section II.b
$230
$230
q
Student/Predoctoral Member
$95
$95
q
Student/Predoctoral Nonmember - complete section II.b
$135
$135
q
AAST Member* - includes CECs for AAST Meeting
$220
$295
q
Technologist (AAST Nonmember) - does not include CECs
$325
$400
q
Guest (Family members only)
$100
$100
Guest Name: ______________________________________________________________
Ticketed Sessions:
All registrants must complete Section II – General Session Registration prior to registering for any of the following
sections. Postgraduate courses, meet the professor sessions, and lunch debate sessions are ticketed sessions and have limited seating. A list of sold
out sessions is available at
Section II.b. -
To register as a student nonmember, you must currently be a student enrolled in a formal training program. Students in the field
of sleep technology are not eligible for this registration category.
q
By checking this box, I am verifying that I am currently a student enrolled in a formal training program. I give permission to contact my
program director to verify my student status. My program director’s name and e-mail are listed below.
Program Director’s Name: __________________________________ Program Director’s Email Address: _____________________________
Full-day Courses
$150 Member, $200 Nonmember
Half-day Courses
$85 Member, $150 Nonmember
Saturday, May 31
q
C01
q
C02
q
C03
q
C04
q
C05
q
C06
q
C07
q
C08
Sunday, June 1
q
C09
q
C10
q
C11
q
C12
q
C13
q
C14
q
C15
Section III - Postgraduate Course Registration -
There is no limit to the number of courses for which you can register
Section III Total:
$____________
Last Name:_______________________________________________ First Name: _______________________________________________
Company:________________________________________________ Department:_______________________________________________
Address: __________________________________________________________________________________________________________
City: _________________________________________ State:_______ Zip Code: ____________ Country: ___________________________
Telephone:________________________ Fax: ________________________ Email Address: _______________________________________
On-site Mobile Number: _________________________________ NPI Number (required for MDs only): _____________________________
Degree(s)
please check:
q
MD
q
PhD
q
RST
q
CPSGT
q
RPSGT
q
DO
q
DDS
q
RN
q
APRN
q
PA
q
Other_____________
Primary Specialty:
q
Sleep
q
Neurology
q
Pediatrics
q
Psychology
q
Internal Medicine
q
Neurophysiology
q
Psychiatry
q
Pulmonary Medicine
q
Family Medicine
q
Otolarynology
q
Anesthesiology
q
Nursing
q
Other
Are you a resident physician?
q
Yes
q
No
Special Services:
q
Please check here if you require special services to fully
participate at the meeting. Attach a written description of your needs.
Monday, June 2
M01- M08 Choice 1: Course #M ____ Choice 2: Course #M ____ Choice 3: Course #M ____
Tuesday, June 3
M09- M16 Choice 1: Course #M ____ Choice 2: Course #M ____ Choice 3: Course #M ____
Wednesday, June 4
M17- M24 Choice 1: Course #M ____ Choice 2: Course #M ____ Choice 3: Course #M ____
Section IV - Meet the Professor Registration -
Fee per session: $55 Member, $65 Nonmember
Section IV Total:
$____________
63
