AVIDSymposium Individual Registration

Personal Information            * Denotes Required Fields

* First Name:
* Last Name (Surname, Family Name):
Degree: If Other:
* Physician or Non-Physician: Physician Non-Physician
Specialty: If Other:
Affiliation:
* Cleveland Clinic Employee? Yes No
* Address Type: Home Other
* Address:
* City:
* State/Province:
* Zip/Postal Code:
* Country:
* E-Mail:
A valid registrant's email address is required for
confirmation and CME Certification
Alternate E-Mail (Secretary/Assistant):
* Phone: U.S. Telephone: - - or
International Telephone:
Cell Phone: U.S. Cell Phone: - - or
International Cell Phone:
Fax: U.S. Fax: - - or
International Fax:
* What source did you use to find out information
   about the AVIDSymposium?		 If Other:
* Are you a returning participant of the AVIDSymposium? Yes No

Full Registration

Technologists $500
Sonographers $500
Residents $500
Nurses $500
Medical & Ultrasound Students *
        * Letter of verification from Dean is required.
 $175
Practicing Physicians $695
Practicing Physicians Combination Rate - VEITHsymposium and AVIDsymposium $1895
PhDs $595
Nurse Practitioners $595
Physician Assistants $595
Exhibitors (This fee applies to only those exhibiting at meeting) $500
Other Allied Health Care Professionals $650

Payment Method

Discount Code (If applicable)
Secure Online Credit Card Select this option to pay securely online now
Check Please note that checks must be received by 10/31/2011 and a copy of the registration form should accompany the check.
Please make checks payable to the Cleveland Clinic Educational Foundation and mail to:
The Cleveland Clinic Educational Foundation
Attn: 020805
P.O. Box 931653
Cleveland, OH 44193-1082
Wire/Bank Transfer Wire transfers will incur an additional $30 to the registration fee. Please note that wires must be received by 10/31/2011 and that the name of the registrant/registrants MUST appear on the wire transfer. Please send e-mail to registrar@AVIDSymposium.org for bank instructions
Complimentary Select this option if your registration is complimentary
Offline Credit Card Credit Card will be processed manually at a later time

I have read and accept that there is a $95 cancellation fee if canceled in writing by October 21, 2011. No refunds will be made thereafter.