4th Annual Meeting Registration Form

4th Annual Meeting Registration Form
📅 Date: July 22–26, 2026 (Wednesday - Sunday)

CME Program: July 23–25, 2026 (Thursday - Saturday)

📍 Location: West Virginia Stonewall Resort
Registration Info
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Which state you are living in?*
Profession (speciality)*
Which institution do you work for?
Number adult attendees*
How many children are attending with you?*
How old is your 1. Child?
How old is your 2. Child?
How old is your 3. Child?
How old is your 4. Child?
What is the gender of your 1. Child

MaleFemale
What is the gender of your 2. Child

MaleFemale
What is the gender of your 3. Child

MaleFemale
What is the gender of your 4. Child

MaleFemale
Full Name of the 2. Adult

First NameLast Name
Email of the 2. Adult
example@example.com
Profession (speciality) of the 2. Adult
Full Name of the 3. Adult

First NameLast Name
Profession (speciality) of the 3. Adult
Email of the 3. Adult
example@example.com
Full Name of the 4. Adult

First NameLast Name
Profession (speciality) of the 4. Adult
Email of the 4. Adult
example@example.com
Please select the days you will be attending the program*

July 22July 23July 24July 25
Payment
Please proceed with the payment for the CME Program and/or the Annual Meeting. Attending the CME program is optional. *
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CME Program for 3 days
Price is per person. Please select the number of attendees.

$100.00 Person

Annual Meeting Program Fee for 4 days
The program fee is fixed, regardless of whether you attend alone or with your family.

$100.00

Total

$0.00
Payment Consent & Refund Policy

I, the undersigned, hereby acknowledge and agree to the following refund terms and conditions regarding my payment:
- 14-Day Refund Window: I understand that a refund request can only be made within 14 days of the initial payment date.
- Final Deadline: Regardless of the payment date, I acknowledge that the absolute final date for any refund request is May 15th, 2026.
- Non-Refundable Period: I clearly understand and accept that any payments made after May 15th, 2026, are strictly non-refundable.
- Written Application: I agree that all refund requests must be submitted in writing via email to annualmeeting@whitetulip.org before the deadlines mentioned above.
By proceeding with this payment, I confirm that I have read, understood, and voluntarily accepted this refund policy.
After you make the payment and submit this form you will be redirected to the hotel page to book your accomadation.
Signature*
Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

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