2010 EMS Odyssey Online Conference Registration
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1. 2010 EMS Odyssey Conference Registration Form

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10th Annual EMS Odyssey Conference
June 3-4, 2010
Marriott Hotel
200 North Centennial Way in Mesa, AZ

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Thank you for registering online to participate in the AEMS 2010 EMS Odyssey Conference.

Please complete the application below. Upon completion, click "Done" and you will be redirected to the PayPal link where you may remit your credit card payment.

You may register for more than one person on this form, but list the main contact person first. Also, provide only one main set of contact information for all applicants.

IMPORTANT: Online registrations will only be processed with receipt of payment. If you prefer to pay with check or money order, return to the AEMS Conference Registration page and download the registration form.

Please note that a nominal online processing charge is included with the registration fee.

Once your registration is processed, we will issue you a confirmation letter and receipt.

Thank you for your support of and involvement with the AEMS 2010 EMS Odyssey Conference!

If you should have any questions, or encounter any problems with completing this application, please contact:

AEMS
Peggy Baker
pbaker@aems.org
623-847-4100

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REGISTRATION INFORMATION AND FORM
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You must complete all information boxes marked with astericks (*) in order to submit your registration.

Upon completion, please click "Done" to be redirected to the PayPal link where you will remit your credit card payment.

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REGISTRATION FEE SCHEDULE

**Registration Fees received on or before April 15:

$114 for AEMS Dues Paying Members (see list below)

$129 for Non-Dues Paying Members (see list below)

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**Registration Fees received after April 15 and before May 20

$145 for AEMS Dues Paying Members

$160 for AEMS Non-Dues Paying Members

+ + + + + + + + + + + + + + + + + + + + + + + + + + + +

NOTE: Registration Fees received after May 20 will be accepted at the door of the conference and pending space availability. The At-the-Door Registration Fee is $195

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**REFUND POLICY: To receive a refund, your cancellation must be received by AEMS via email, mail, or phone on or before May 15th. All refunds will be issued within 30 days of notice less a $5.00 handling fee.

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**2010 AEMS Dues Paying Members:

Air Evac Services
Apache Junction Fire Department
Arizona Hospital & Healthcare Association
Avondale Fire Department
Banner Baywood Medical Center
Banner Desert Medical Center
Banner Estella Medical Center
Banner Gateway Medical Center
Banner Good Samaritan Medical Center
Banner Thunderbird Medical Center
Beaver Valley Fire District
Black Canyon Fire District
Buckeye Valley Fire District
Casa Grande Fire Department
Chandler Regional Hospital
Cobre Valley Community Hospital
Eloy Fire District
Florence Fire Department
Gilbert Fire Department
Gilbert Hospital
Gisela Valley Fire Department
Glendale Fire Department
Globe Fire Department
Harquahala Valley Fire District
John C. Lincoln Hospital – Deer Valley
John C. Lincoln Hospital – North Mountain
Life Line Ambulance
Maricopa Fire District
Maricopa Medical Center
Mayo Clinic Hospital
Mercy Gilbert Medical Center
Mesa Fire Department
Mountain Vista Medical Center
Payson Fire Department
Peoria Fire Department
Phoenix Children’s Hospital
Phoenix Fire Department
Phoenix St. Luke’s Hospital
Pleasant Valley Volunteer Fire Department
PMT Ambulance
Regional Fire & Rescue
St. Joseph's Hospital and Medical Center
Scottsdale Fire Department
Scottsdale Healthcare - Osborn
Scottsdale Healthcare - Shea
Scottsdale Healthcare - Thompson Peak
Southwest Ambulance
Sun City Fire District
Sun City West Fire District
Surprise Fire Department
Tempe Fire Department
Tempe St. Luke’s Hospital
Tonopah Valley Fire District
Tonto Basin Fire District
Whispering Pines Fire District

**2010 AEMS Membership Dues Campaign is currently ongoing. This list is updated weekly. If you do not find your agency/hospital, please refer to the AEMS website at www.aems.org OR contact your employer to determine if they are in the process of renewing their membership.

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1. Registrant Name(s) - if registering for more then one person, please include all names:

Registrant Name(s) - if registering for more then one person, please include all names:

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2. Registrant's Title(s) - RN, EMT, IEMT, Paramedic, Physician, etc:

Registrant's Title(s) - RN, EMT, IEMT, Paramedic, Physician, etc:

*
3. Registrant's Agency/Hospital Affiliation - if none, state n/a:

Registrant's Agency/Hospital Affiliation - if none, state n/a:

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4. Complete Mailing Address - Street/PO Box, City, State, & Zip:

Complete Mailing Address - Street/PO Box, City, State, & Zip:

*
5. Day Phone - include area code:

Day Phone - include area code:

6. Email:

Email:

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PAYMENT INFORMATION
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Upon completion of this registration form, you will be redirected to the PayPal link where you will remit credit payment. However, we request the following information so that we may cross reference your registration with your PayPal credit card payment.

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7. Conference Registration Fee (select one from drop-down menu)

Conference Registration Fee (select one from drop-down menu)

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8. Total Amount of Conference Registration Fee(s):

Total Amount of Conference Registration Fee(s):

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9. Name on Credit Card

Name on Credit Card

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Congratulations! You have completed the 2010 EMS Odyssey Online Registration form. Click "Done" and you will be redirected to the PayPal link where you will remit your credit card payment. Payment must be received in order for your registration to be processed. Thank You!
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2010 EMS Odyssey Online Conference Registration Exit this survey >>

1. 2010 EMS Odyssey Conference Registration Form

*1. Registrant Name(s) - if registering for more then one person, please include all names:

*2. Registrant's Title(s) - RN, EMT, IEMT, Paramedic, Physician, etc:

*3. Registrant's Agency/Hospital Affiliation - if none, state n/a:

*4. Complete Mailing Address - Street/PO Box, City, State, & Zip:

*5. Day Phone - include area code: