New Fellow Annual Meeting Registration Annual Meeting 2019 Packages and Sessions Are you, or is the individual for whom you are registering, a current Ohio AAP member? * Yes - $0 No - $170 N/A - I am not a physician - $0 If you are unsure about current Ohio AAP membership status, please contact Hayley Southworth (firstname.lastname@example.org). For individuals who are not current members of one of the listed organizations, Annual Meeting fees will include $170 membership fee. This $170 membership fee applies only to physicians. Please select the 2019 Annual Meeting Package(s) for which you would like to register: * Champion for Children (two-day) Package - $75 Friday Only - $58 Saturday Only - $50 Friday Luncheon Only Champion for Children Package – Friday Luncheon (1 attendee), Friday MOC/CME Tracks, Friday Awards Ceremony, Saturday Breakfast, Saturday Sessions Friday Only - Luncheon (1 attendee), MOC/CME Tracks, Awards Ceremony Saturday Only - Saturday Breakfast and Saturday Sessions Friday Luncheon Only - Pricing below For the Friday Luncheon only, please choose your number of tickets. * 1 ticket - $30 2 tickets - $60 4 tickets - $120 Table of 8 (includes sponsorship recognition) - $750 Please select your preferred session for Friday from 1:00 - 2:00pm * Integration of Mental Health, Anxiety and Depression DeWine Administration Update/Building on the Keynote Ohio Parents Advocating for Vaccines Training Please select your preferred session for Friday from 2:30 - 3:30pm * New Developments in School Age and Adolescents Panel Pitch Your Pediatric Policy! Advocacy Simulation Activity On Saturday morning, do you plan to attend the breakfast meeting from 8:30 - 10:00am? * Yes No Please select your preferred track for Saturday from 10:30 am - 12:30 pm * PMP, Feeding, Nutrition and Breastfeeding Panel Reversing the Irreversible: Adolescent Suicide and Store It Safe Panel Thinking Developmentally & Trauma-Informed Care in the Opioid Crisis Your Annual Meeting Package includes the 2019 Ohio AAP Poster Session and Awards Reception, which will take place on Friday Evening from 5:30 - 7:00pm. Would you like to register any additional guests for the reception? * Yes No How many additional guest would you like to register for the Awards Reception? * ----- 1 - $15 2 - $30 3 - $45 4 - $60 5 - $75 6 - $90 7 - $105 8 - $120 9 - $135 10 - $150 Name(s) of Awards Reception Attendees On Friday, Sept. 27, 2019 from 7:00 - 10:00 pm, the Ohio AAP Foundation will be hosting its Sips and Secrets Fundraiser. Would you like to purchase tickets for this event? * Yes No How many Sips and Secrets Tickets would you like to purchase? * ----- One - $85 Two - $160 Four - $320 Your ticket purchase includes 2 drink tickets per person, as well as chips for the event. Name(s) of Sips and Secrets Attendees I would like to make an additional donation of ________ to the Ohio AAP Foundation. Subtotal: Discounts Did you participate in one of the Ohio AAP's Quality Improvement (QI) Projects during 2018/2019? * Yes - Discount of $25 No Name of QI Project ---- EASE - Hospitalist Safe Sleep LC Injury Prevention/Safe Sleep LC Injury Prevention/SEEK LC HPV Quality Improvement LC Ohio QI2U - Adolescent Health Program Ohio QI2U - MenB Program Parenting at Mealtime and Playtime LC Smoke Free Families LC TALK Adolescent LC TRAIN LC Other Available Discounts * First Time Attendee: $25 New Member: $25 Poster Presenter: $25 Peds on Call Member: $50 None of the above discounts are applicable Only one discount per attendee ($25 discount for QI Project participants can be combined with one of the above discounts) Attendee Information Name * First Last Name and Credentials * Last, Credentials Organization/Practice * Street Address * Street Address 2 City * State * Ohio Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Zip * Phone Number * Email Address * Facebook Name/Handle Information will be only used to tag attendees in selected posts relating to Annual Meeting 2019 Twitter Handle Information will be only used to tag attendees in selected posts relating to Annual Meeting 2019 Name for Badge * Please include any credentials that you would like to have on your badge (MD, DO, FAAP, MPH, etc.). What made you register for the meeting? (Check all that apply) * Interesting Topics Need for MOC Part II Credit Networking with Colleagues Shark Tank I was referred by:I was referred by: OtherOther How did you hear about the meeting? (Check all that apply) * Email Blast Ohio AAP Today Ohio Pediatrics Ohio AAP Website Personal Referral/Colleague Postcard in Mail Practice Recruitment Visit OtherOther Total Due ($): You will receive information on hotel accommodations in the email confirmation you receive after payment. If you are human, leave this field blank.