2020 Annual Meeting Registration Form

I would like to make an additional donation of ________ to support the Store It Safe program of the Ohio AAP Foundation.

(Optional Donation)

I would like to purchase raffle tickets to support the Store It Safe program of the Ohio AAP Foundation.

(Optional raffle ticket purchase. Raffle tickets will be provided the week of November 16 to those with advance purchases; additional raffle tickets will be sold during the Store It Safe Fundraiser November 20. Raffle prizes will be announced in November 2020.)

How you would like your donation recognized in print (individual name, name with partner or family, organization, etc.).

Subtotal:

Attendee Information

Name *

First

Last Name and Credentials *

Last, Credentials

Organization/Practice *

Preferred Street Address to Receive Mailed Meeting Materials (if provided) *

Street Address 2

City *

State *

Zip *

Phone Number *

Email Address *

Facebook Name/Handle

Information will be only used to tag attendees in selected posts relating to Annual Meeting 2020

Twitter Handle

Information will be only used to tag attendees in selected posts relating to Annual Meeting 2020

What made you register for the meeting? (Check all that apply) *

Interesting Topics

Need for MOC Part II Credit

Networking with Colleagues

Virtual Format

I was referred by:I was referred by:

OtherOther

Total Due ($):

Text

Annual Meeting 2020 Packages and Sessions

Attendee Information