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* 1. AAFP ID 

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* 2. Full Name 

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* 3. Nickname for Badge

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* 4. Designation (Select all that apply)

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* 5. Are you a Fellow of the AAFP (FAAFP)?

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* 6. City, State

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* 7. Phone Number

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* 8. Email

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* 9. I will be present for the following 

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* 10. A guest will be joining me for the Friday Night Reception

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* 11. Thursday KSA Selection (included in full-conference and Thursday only registration prices)

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* 12. Sunday KSA Selection (included in full-conference and Sunday only registration prices)

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* 13. Syllabus Choice

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* 14. Please list the first and last name(s) of any guests joining you for the Friday night reception or Trivia Night on Saturday:

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* 15. Your Full Conference Registration fee includes up to four tickets for Trivia Night on Saturday. Included tickets may be used for adults or children. Additional tickets may be purchased at our Square Store. Please indicate below how many tickets (total) you will use.

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* 16. I am planning the following hotel accommodations

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* 17. Special Needs

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* 18. CONSENT TO USE OF PHOTOGRAPHIC IMAGES: Registration and attendance at, or participation in, IAFP meetings and other activities constitutes an agreement by the registrant for IAFP use and distribution (both now and in the future) of the registrant or attendee’s image or voice in photographs, videotapes, electronic reproductions, and audiotapes of such events and activities.

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* 19. CANCELLATION POLICY: You may cancel without penalty if cancellation request is received up to one week prior to the start of the conference. Due to financial obligations incurred by the IAFP, refunds or credits may not be issued for cancellation requests received less than one week prior to the start of the event.

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