MoSRT - Conference Registration (v1.6b)

Missouri Society of Radiologic Technologists
- 93rd Annual Conference Registration -

April 2nd, 3rd and 4th, 2025
Please note the following when answering the following question:

If you hold any sort of imaging/therapy credential(s)

then you are considered a technologist and NOT A STUDENT.
If you have any food allergies or special needs, please contact our Conference Coordinator.
Are you registering as a Student, Technologist, or Speaker?*

StudentTechnologistSpeakerOther
For Speakers: Please note. Select which days you will be present under the "Current Pricing Package". Make sure you select the option that allows you to mail in your ticket payment. This will prevent you from being charged upfront, in exchange for speaking at our event. Thank you.
Full Name:*

First NameMILast NameSuffix
Home/Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you an ASRT Member?*

YesNo
ASRT Number:
ARRT Number: (if applicable)
Phone Number (Primary):*
Phone Number (Work):
Your Primary Email Address:*

Confirmation Email
Your Alternate Email Address:

Confirmation Email
Employer:
Employer Address:

Street Address

Street Address Line 2

CityState

Zip Code
School:
School Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Graduation Date (students):

MonthDayYear
Are you a MoSRT or other ASRT Affiliate Member?*

YesNo
Certifications:

RadiographyMammographyComputed TomographyMagnetic ResonanceNuclear MedicineSonographyCardiovascular-InterventionalRadiation TherapyQuality ManagementBone Densitometry
Your Academic Credentials:
Ticket Information
Reminder:

If you hold any sort of imaging/therapy credential(s)

then you are considered a technologist and NOT A STUDENT.

Current Pricing Package: Early Bird
You have selected TECHNOLOGIST MEMBER. Which days will you be attending?*

Technologist (Member) Wednesday Ticket: $150.00Technologist (Member) Thursday Ticket: $150.00Technologist (Member) Friday Ticket: $150.00Technologist (Member) Wed, Thurs, Fri Combo Package: $270.00
You have selected STUDENT MEMBER. Which days will you be attending?*

Student (Member) Wednesday Ticket: $110.00Student (Member) Thursday Ticket: $110.00Student (Member) Friday Ticket: $110.00Student (Member) Wed, Thurs, Fri Combo Package: $210.00
Meals
Due to rising food costs and as an effort to be fiscally responsible, the MoSRT needs to get a more accurate headcount for meal totals. Please indicate below whether or not you plan to attend these meals. Make sure you consider the following points before replying:
- Do you think you will have any difficulty waking up to attend the breakfast meals?
- Does the meal being offered sound like something you will eat?
- Will you be leaving after the final lecture on Friday?
- Will you have your own transportation to go get food if you miss one of our meals?
- There is an onsite restaurant/bar that may or may not be opened depending on the time of day.
Standard daily meals (select as many or as few as you would like)

Wednesday - Dinner - "Taco Street Shredded Chicken, Seasoned Beef, Refried Beans/Rice, Taco Shells, Flour Tortillas, Cheese, Jalapenos, Olives, Lettuce, Salsa, Sour Cream. Churros with Honey"Thursday - Breakfast - "Buffet: Rise & Shine - Sliced Seasonal, Fruit & Berries, Fruit Yogurts, Farm Fresh Scrambled, Eggs, Applewood Smoked Bacon, Sausage, Breakfast Potatoes or Cheesy Grits, French Toast with Pure Maple Syrup, 2% Milk"Thursday - Boxed Lunch - "Box Lunch - Choice of Turkey/Ham, a Cookie, a Bag of Chips, Individual, Packet of Mustard, Mayonnaise, Whole Fruit, and a Soda or Bottled Water"Friday - Breakfast - ""Buffet: Rise & Shine - Sliced Seasonal, Fruit & Berries, Fruit Yogurts, Farm Fresh Scrambled, Eggs, Applewood Smoked Bacon, Sausage, Breakfast Potatoes or Cheesy Grits, French Toast with Pure Maple Syrup, 2% Milk""Friday - Lunch - "Smothered Chicken - Boneless Chicken Breast, Bacon, Onions,Mushrooms, Spinach, and Cream"I do not plan on eating any meals.
Will you be attending the banquet on Friday night which begins at 6:15pm and runs until 8:00pm? Please select one of the options below:

I will not be attending the FRIDAY Banquet which begins at 6:15pm.Char-Grilled Atlantic Salmon with a Port Wine Reduction6ox Sirloin Steak Sauteed with Onions, Mushrooms, Peppers, and a Whiskey Demi-Glaze
Please confirm whether or not you will be staying for the banquet on Friday which begins at 6:15pm and runs until 8:00pm.

No, I will not be attending the banquet which begins at 6:15pm on Friday.Yes, I will be attending the banquet on Friday and I have selected my meal in the previous question.
Do you have any dietary restrictions that we should know about?

YesNo
What are your dietary restrictions?
Will you need any guest meal tickets?*

YesNo
Which days/meals will you need guest meal tickets for?

Wednesday - Mixer ($23)Thursday - Breakfast ($20)Thursday - Lunch ($20)Friday - Breakfast ($20)Friday - Lunch ($25)Friday - Banquet Salmon ($40)Friday - Banquet Chicken ($40)
Ticket Total:
BADGE INFORMATION
Name and credentials you want printed on badge:*
Days you are Attending:

WEDNESDAYTHURSDAYFRIDAY
Member Type:*
Please check any/all that apply:

Conference FacultyMoSRT Past PresidentDistrict PresidentFellow of the ASRTFellow of the MoSRT
GUEST BADGE INFORMATION
GUEST Name and credentials you want printed for your GUEST badge:
GUEST Days you are Attending:

WEDNESDAYTHURSDAYFRIDAY
GUEST Member Type:
GUEST Current Position:
Guest Recommended By:
Payment Wizard
If you do not purchase your tickets using the payment wizard below, you will be responsible for sending your payment to the MoSRT Executive Treasurer.*

I will submit my payment using the payment wizard below.I will be sending my payment as a check or money order to the MoSRT Executive Treasurer to the address included on my registration receipt.
If you/your school do not purchase your tickets using the payment wizard below, you/your school will be responsible for sending your payment to the MoSRT Executive Treasurer.*

I will submit my payment using the payment wizard below.My school will be sending my payment as a check or money order to the MoSRT Executive Treasurer at the address included on my registration receipt.
I will be sending in a check/money order for the amount of:
If you will be submitting a check/money order please send it to the following address:

MoSRT Executive Treasurer
Janet E. Akers-Montgomery
5840 Busiek Road
Farmington, Mo 63640

Should be Empty:

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Missouri Society of Radiologic Technologists

- 93rd Annual Conference Registration -

For Speakers: Please note. Select which days you will be present under the "Current Pricing Package". Make sure you select the option that allows you to mail in your ticket payment. This will prevent you from being charged upfront, in exchange for speaking at our event. Thank you.

Ticket Information

Meals

BADGE INFORMATION

GUEST BADGE INFORMATION

Payment Wizard