Walk-In Registration

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• October 20-22, 2023
  Suncadia Resort and Spa
  Cle Elum, WA

• Contact Information

• Name*
  First Last Credentials (MD, DO, PhD, etc.)
• First Name for Badge (If Different than Above)
• Group / Hospital Name*
• Address*
  Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code
• Phone
• Email*
• Contact Information Sharing
  • By providing your consent, WSDA will only share your name and city with registered exhibitors. None of your other identifying contact information entered on this form will be shared.

• Registration & Payment Information

• Conference registration fee includes your three-day conference tuition, e-syllabus, opening night reception, as well as all breakfasts and refreshment breaks. The Saturday Night Dinner Banquet is free for the attendees. Guest are invited to dinner, please register your guest below.

   

• Registrant*
  • General Registrant
  • Speaker
  • Board President
  • Guest Attendee
  • PT Speaker
  • Staff
• CONFERENCE REGISTRATION*
  • WSDA Member: - $500.00
  • Non-Member: - $675.00
  • Retired: - $350.00
  • Advanced Practice Clinicians: - $375.00
  • Resident-Member: No Charge - $0.00
• I will be attending the dinner (included with registration)
  • Yes
  • No
• No. of adult dinner guests:
  Adult dinner guests are $75.00 each
  Select # of adult dinner guestsOne guest - $75.00 - $75.00Two guests - $150.00 - $150.00Three guests - $225.00 - $225.00Four guests - $300.00 - $300.00
• No. of child dinner guests
  Children ages 5-12 are $35 each; children under 5 years old are free.
  Select # of child dinner guestsOne child guest - $35.00 - $35.00Two child guests - $70.00 - $70.00Three child guests - $105.00 - $105.00Four child guests - $140.00 - $140.00
• Coupon
  
• TOTAL
  $0.00
• Payment Type*
  • Credit Card
  • Check
• Check Number*
• CREDIT CARD*
  American Express

  Discover

  MasterCard

  Visa

  Supported Credit Cards: American Express, Discover, MasterCard, Visa

  Card Number Expiration Date Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code   Cardholder Name
• CANCELLATION POLICY: We must receive written notification of your cancellation. A $50 processing fee will be deducted from the registration refund. No refunds after September 5, 2023.
  
  INQUIRIES:
  Contact Delphi Locey, Association Executive, at the WSDA Office at (206) 956-3650 or send emails to washingtonderm.org.

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