Registration Form
Name
First Name
Last Name
How would you like your name printed on your name badge?
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Company Name:
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Title:
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(Ex: Owner / RN, PA-C)
Email Address:
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example@example.com
Mobile Phone Number
*
Please enter a valid phone number.
Home Address
*
Street Address
Street Address Line 2
Home Country
Home State / Prov. Code
Home Zip / Postal Code
Any Dietary Restrictions:
*
Are you attending the Meet and Greet Dinner with Galderma on Friday (February 2nd) evening?
*
Yes
No
Scrub Size
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L
S
XL
M
Medical License:
*
Years of Experience:
*
Have you attended the cadaver lab before
*
Yes
No
Other cadaver lab:
*
How did you learn about the event?
*
Photograph & Video Release Form
Consent Date:
*
-
Month
-
Day
Year
Date
Emergency Contact
Emergency Contact Name:
*
Emergency Contact Phone Number:
*
Payment Method
The AAI Cadaver Lab is now offering attendees to pay for the lab experience in four monthly installments, in which the attendee consents to having the payment withdrawn from their bank account on the first of each month. Please select your preferred payment method
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Early Bird One Time Payment
$
4,895.00
one-time payment
Four Monthly Installments
$
1,224.00
for each
month
Credit Card
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