Registration Worksheet The "SUMMIT" Salt Lake City

Embed Size (px)

DESCRIPTION

Want to figure out what your registration will be for The "SUMMIT" Salt Lake City an EMS Associates Conference use this Registration Worksheet. Also, don't want to complete your registration online and would rather send it in the mail. There is a form attached for that.

Citation preview

  • ! !!!!

    www.emsassociates.com

    !

    38th Annual

    !

    The Summit in Salt Lake City

    (An EMS and Emergency Services Conference)

  • !BUNDLE PACKAGES and PreCon Sessions

    ***ALL PreCon Sessions are held on Wednesday, November 192014

    TheComplete Conference (3) Full days, + One PreCon

    PreCon Choices are either 4 or 8 hours in length as indicated below !

    4 Hour Class Package (choose either AM or PM session) ***BONUS*** the 4 hour package includes the option for you to add, one of the Evening Education Sessions at 50% off the published price of $75.00. This class discount will be applied to your attendee record during registration). ** Advanced Moulage 2.0 (Warner) **Includes Lab Fee ** 12 Lead Interpretation (Made Easy) (Yost) **Includes lecture material ** Airway Interventions and Resources (Bolleter) ** EMS Incident Command-Organizing Chaos (Bouvier) !8 Hour Class Package ** Nursing - Practical Skills Day ** LIVE Fire Training SLC Fire Training Center ** SAVE a COP Tactical Medicine - LEO, EMS, Military

    $410.00 (Choose Cutting Edge from the dropdown menu during online registration to receive this pricing)

    TheUpgrade Complete Conference (3) Full days

    PLUS - (ONE 2hr. EVENING PreCon Session 7-9pm, 11/19) !** IO/IV with Scotty B (Bolleter) ** K9 Emergency Field Care (Dick/Halcome)

    $370.00 (Choose Evening Arrival from the dropdown menu during online registration to receive this pricing)

    !

  • !Registration WORKSHEET

    The Main Conference Only... (3) Full days/NO PreCon (Thursday Saturday)

    $295.00 (Choose Main Conference Only from the dropdown menu during registration to receive this pricing)

    NOTE:PreCon Session at the class prices listed for each session on the Registration

    Worksheet below...be sure that they dont compete for the same time...

    BUNDLE PACKAGESConference)

    NOTE: If you are purchasing for more than ONE attendee multiply price by # of attendees

    **NOTE: If you are responsible for registering more than ONE attendee...please send a separate list

    stating which attendee is attached to which PreCon

    If paid BY

    11/14

    If paid AFTER 11/14

    Total

    The Cutting Edge Packages Select Cutting Edge from the dropdown menu (multiply number of attendees)

    $410.00

    $450.00

    The Evening Arrival Package withPreCon Upgrade

    Select Evening Arrival from the dropdown menu (multiply number of attendees)

    $370.00

    $400.00

    The Main Conference Only Package Select Main Conference Only from dropdown menu (multiply number of attendees)

    $295.00

    $325.00

    !

  • **PLEASE NOTE: If you choose to ADD an additional PreCon (AM/PM or evening), you will be charged an additional amount at that

    individual PreCon rate. Please enter PreCon Plus as your discount code at the START of

    registration. OR... You may choose an A la Carte Option... (Individual selections)

    You may pick one, two or even three PreCon sessions (an AM/PM and the evening session)

    A la Carte Options***Classes listed below are Wednesday, November 19, 2014

    LIVE Fire Training Salt Lake City Fire Hands-on Course (Ladder, Hose, SCBA)

    (8hr.) 8-5pm

    $185.00

    $195.00

    Nursing Track Emerging Trends (8hr.) 8-5pm

    $185.00

    $195.00

    Save a Cop (EMS, LEO, Military) Tactical Medicine/Active Shooter

    (8hr.) 8-5pm

    $185.00

    $195.00

    12-Lead Interpretation Made Easy

    (Includes Training Material) (4hr)

    AM Session (8am-12pm)

    $150.00

    $160.00

    12-Lead Interpretation Made Easy

    (Includes Training Material) (4hr)

    PM Session (1pm-5pm)

    $150.00

    $160.00

    ADVANCED Moulage 2.0 (Includes Lab Fee)

    (4hr)

    AM Session (8am-12pm)

    $150.00

    $160.00

    ADVANCED Moulage 2.0 (Includes Lab Fee)

    (4hr)

    PM Session (1pm-5pm)

    $150.00

    $160.00 !

    !

  • !Airway Intervention and Resources Instructor - BOLLETER (4hr)

    AM Session (8am-12pm)

    $175.00

    $195.00

    Airway Intervention and Resources Instructor - BOLLETER(4hr)

    PM Session (1pm-5pm)

    $175.00

    $195.00

    EMS Incident Command Instructor - BOUVIER(4hr)

    AM Session (8am-12pm)

    $175.00

    $195.00

    EMS Incident Command Instructor - BOUVIER(4hr)

    PM Session (1pm-5pm)

    $175.00

    $195.00

    **(3) Evening Sessions** November 19thIO Access Skills Bolleter 7pm-9pm $75.00 $95.

    00

    K9 Emergency Care-Dick/Halcome

    7pm-9pm $75.00 $95.00

    Operation KIDS Vehicle Restraint and Transport of Children Janet Brooks

    7pm-9pm FREE FREE

    Individual Conference Day(s) (Thursday, Friday or Saturday)

    $185.00

    $195.00

    Add up all of your selections and total the amounts...

    Sub TOTAL:

    Utah State Sales Tax add 6.85% (if tax exempt, includea copy of your tax exempt letter or certificate with your registration)

    TAX: (6.85%)

    Total Registration Amount Total:

    !

  • !Last Name: First Name:

    Street Address (Include PO Box):

    City: State: Zip:

    Phone: Work Phone:

    E-Mail: EMS Department E-Mail:

    Affiliated Title and Agency (Department) Agency Address:

    Payment Method (Select Option)

    Check Enclosed Make checks payable to: EMS Associates Mail to Framework (address below)

    Purchase Order Credit Card

    PURCHASE ORDER #(terms = net 30 days)

    Company Name:

    Billing Address:

    E-Mail Address:

    City: State: Zip:

    !

  • MAIL COMPLETED FORM TO: Framework Meetings and Destinations

    Attn: Registration, The "SUMMIT" SLC 2014 2192 E. Grandview Drive Coeur d'Alene, ID 83815

    !Cardholder Name:

    Billing Address:

    City: State: Zip:

    Card Number: Expiration Date and CVV code:

    Authorized Signature:

    Contact Person: Phone:

    E-Mail Address (required for credit card payment):

    CREDIT CARD PAYMENT

    !

    !