Name:
   
Address:   
City, State, Zip:   
Phone:   
Email:   
Payment:
AAFP Member Practicing Physician $385
Non-member Practicing Physician $500
NP/PA/Nurse $300 NP PA Nurse
Retired Physician $100
Family Medicine Resident (no charge)
Medical Student (no charge)
Yes, I want to sponsor a student attendee $40
Extra Ticket for Thursday Welcome Reception
children (6-12) x $8 =
adults x $16 =
Extra Ticket for Friday Dinner & Dance
children (6-12) x $15 =
     (children under 5 are free)
adults x $30 =
Total:
Card number:

Expiration date:
Month: Year:

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