CRNA Educational Conference Registration Form

Full Name

First NameLast Name

Title

Email

personal email recommended

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., ]

CityState

Zip Code

Employer

Town and name of facility

Please note that this option DOES NOT HAVE A POST TEST.

It is self directed with an assigned moderator per the

AANA PDIS program requirements.

SHOULD YOUR EMPLOYER REQUIRE A POST TEST FOR CE COURSES YOU NEED TO GO TO OUR ON DEMAND PLATFORM @ https://sasllc.ksucrna.com/ and purchase your program rather than complete this registration form.

Phone Number

Area CodePhone Number

How did you hear about us?

Who referred you?

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

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.

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.

My Products

Conference Registration *20 per credit. Step 1: Select number of courses hours you desire. We have 100 CE hours available at this time. If you would like all 107 please indicate 107 in box below and there is no need to select courses below :)

Conference Registration *20 per credit$20.00

Step 1: Select number of courses hours you desire. We have 100 CE hours available at this time. If you would like all 107 please indicate 107 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. The remaining modules are under production and will be submitted for NBCRNA approval in 2023.

Please include Core Modules in my program!$60.00

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. The remaining modules are under production and will be submitted for NBCRNA approval in 2023.

Core Module options	Quantity	Price
Individual core module: Airway Management Module 1.5CE		$60.00
Individual core module: Anesthesia Equip & Tech Module 3CE		$90.00

CE subscription plan. 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!

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

Credit Card

Courses are valued at 1 Class A CE unless otherwise noted.

llStep 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?

Would you like a custom brochure as part of your program for 1099 tax expense purposes? If yes, note 2 day minimum (10 CE required) for US and 4 day minimum for international.

Conference start date for brochure

Date

Conference end date for brochure

Date

Any requests/comments for our staff to add to brochure? Location and dates are common responses.

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

Acknowledgment statement

Did you choose a quantity for purchase? if not your program release will be delayed and an invoice issued

Did you make your course selections for your "create your own" conference? See step 2 above

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 Educational Conference Registration

My Products

Credit Card