CRNA Create your own Conference Registration Form

Full Name *

First Name Last Name

Title

Certification/AANA Number *

This is located on your NBCRNA card. In order to record your credits accurately and promptly please double check your response is accurate

Address *

Street Address

Additional information [ Apt no. etc., ]

City State

Zip Code

E-mail address that you would like CE package delivered to: *

When is your next recertification? Your certification is for 4 years. 2020 recertification expires in 2024, 2021 expires in 2025 and so on. If you are a new grad CRNA it is 4 years from your certification month. *

Year Month Day

Employer

Town and name of facility

Phone Number *

Area Code Phone Number

How did you hear about us? *

Who referred you?

We reward referrals! Tell us who and we will thank them!

My Products

Conference Registration *20 per credit $ 20.00

Step 1: Select number of courses hours you desire. We have 92 CE hours available at this time. If you would like all 92 please indicate 88 in box below and there is no need to select courses below :)

Quantity

Please include Core Modules in my program!

SAS is an NBCRNA approved core module provider. You can add the module to your create your own conference week or purchase now and access at your convenience! If you select the bundle, we have marked the price down 30% for you! Work at your own pace. Modules available for access through approval dates. Airway module [1.5CE] & Equipment/ tech [3CE] available immediately. Next release will be Applied Clinical pharmacology module in winter 2021. Reminders with program release and prior to program expiration. Get yours today!

Core Module options	Quantity	Price
Core Module Bundle prepurchase: The bundle includes all 4 required core modules valued at 20CE. Access Airway Management & Equipment/tech Core Modules now. Remaining modules released quarterly		$ 299.00
Individual core module: Airway Management Module 1.5CE		$ 60.00
Individual core module: Anesthesia Equip & Tech Module 3CE		$ 90.00
I already purchased the Airway Management module please upgrade me to the bundle		$ 239.00
i already purchased the Anesthesia Equipment & Tech module, please upgrade me to the bundle		$ 209.00

CE subscription plan $ 1.00

Need to purchase a plan you can access at anytime? This plan allows you to PREPAY with your CE funds and apply toward any Summit Anesthesia program whenever you are ready. Your credits NEVER expire!

Value in dollars that you would like to prepurchase

Enter coupon

Total $ 0.00

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Coupon Codes:

Please enter Coupon code above if we have issued one to you. If you are a member of the military, enter code MILITARY and note details below.

Military 20% Discount! Enter the coupon code MILITARY in the coupon code section above!

Thank you for your service! Please enter Branch and rank for discount.

Step 2. If you would like to build your own conference, please Select your courses from the list. Courses are 1 Class A CE unless noted otherwise. Make sure you select the quantity above so final amount due is accurate. Note the name of presenter next to the title

How would you like your custom program delivered to you? *

Google Drive link (released via email within 24 hours) USB drive mailed to me (allow for 5-7 day delivery time)

Would you like a custom brochure as part of your program? *

What type of brochure?

Destination conference Virtual conference only -no destination necessary

Conference start date for brochure

Date

Conference end date for brochure

Date

Total conference days requested

Please assure you have purchased the correct amount to avoid program build/delivery delays. SAS requires 5 CE per destination conference date.

Location specifics for brochure

If you have selected a core module as part of your purchase today, would you like that added to your program brochure? *

Yes, please add the modules I purchased to my program brochure [Airway valued at 1.5Class A CE and Equipment/tech module valued at 3Class A CE] are available at this time for immediate access. No. I do not want the core module(s) I purchased listed on the brochure. I will access them at another time I did not purchase core modules, this does not apply to me

Acknowledgment statement *

By clicking this acknowledgement box, you are aware our staff will contact you if adjustments are required prior to program release, specifically if the 5CE per day for destination brochure request is not met. I am not requesting a destination brochure, this rule does not apply to me

Conference registration is NOT COMPLETE until payment is submitted.

You will be redirected to PayPal for completion of payment. You can pay with any major credit card. PayPal membership is NOT REQUIRED. Just choose the pay with credit card option.

SAS CRNA Create Your Own Conference Registration