2025 NCS-ACOFP Conference Attendee Registration Form

Attendee Registration Form

NCS-ACOFP 2025 Annual Conference
Name and Suffix (e.g., DO, MD, PA, FNP, OMS)*

First NameLast NameSuffix
Email*
example@example.com
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you are a practicing physician, please enter the physical address of your practice.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The registration fee includes breakfast, lunch and snacks. If you have any dietary allergies, please describe below.
Please indicate which meals you plan to attend:*

Friday breakfast - check this only if you are not staying at the hotel and you wish to eat the breakfast buffet offered to hotel guests. If you check this, a breakfast voucher can be provided.Friday lunchFriday receptionSaturday breakfastSaturday lunchSunday breakfast -check this only if you are not staying at the hotel and you wish to eat the breakfast buffet offered to hotel guests. If you check this, a breakfast voucher can be provided.

Registration Fees *

NCOMA or NCS-ACOFP Member

(You must be a member of one of the NC chapters for this rate to apply.)

$525.00

Non-member Physician

(Rate applies to individuals who are not a member of NCS-ACOFP or NCOMA. Membership will be verified.)

$575.00

Active Duty Military Physician (not a member)

$325.00

Retired Physician

$375.00

Student

$45.00

Resident

$100.00

Other Health Care Professional (PA, RN, FNP, etc. )

$350.00

Guest (For Friday evening reception only)

$40.00 Quantity

Donation to Sponsor Student Attendance

Your donation will be used to assist with paying hotel costs for students to attend the conference.

$100.00 Quantity
Item subtotal:$0.00

Total

$0.00