Registration includes Friday lunch and dinner, Saturday breakfast and lunch, and snacks.  

Regular Registration (on or after May 1):  $200

Online registration will close on August 10, 2009 at 5:00 PST.

Payment options include check or credit card.

* Required information

* First Name:
* Last Name:
Practice Name:
* Practice Address:
Address cont'd:
* City:
* State:		Select One Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Vigin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Africa Armed Forces Americas Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon International
* Zip Code:
* Practice Phone:
Cell Phone:
Website:
* E-mail:
		Conference attendee information will be given to attendees for contact during the meeting. If you do not want your information released please check this box:
Scholarship:  Please check if you need help with conference expenses. *Friday Night Banquet: This is included in the Camp registration fee.  Additional guest tickets are $30.  How many people (including friends/family) will be attending?   Select One 0 1 2 3 4 5 6 7 8 9 10 *Saturday Evening BBQ and Party: This not included in the Camp registration fee. Tickets are $30.  How many people (including friends/family) will be attending?    Select One 0 1 2 3 4 5 6 7 8 9 10 Camp 2008 Video/Audio Presentations: Registrants will receive some Camp pre-work to review before Camp (a few articles to read, etc).  If you would like a copy of the video/audio presentations from last year’s camp to review please check this box: If you attended last year’s camp, there is no charge; if you were not able to make it, there is a $12 fee. Your Practice: I am: a primary care medical provider (physician or nurse practitioner) an IMP doctor's team member Specialty:  Select One Endocr FM IM Neuro Peds Primary Care Specialty Care IMP Team Member (MA, receptionist, nurse, etc.)                  Other:  Years in practice post-residency:  Select One None 1-2 3-5 5-10 10-20 Greater than 20 Team Role:  Select One Billing Patient Education Medical Assistant Reception Other   Other: EMR: Select One None AC eMDs Soapware Alteer Welford Self-Developed Other Ideal Medical Practice: Have you participated in an IMP cohort? Yes No Do you use HowsYourHealth with your patients? Yes No If contemplating an IMP: When do you anticipate opening? Select One Less than 6 months 6-12 months 1-2 years Maybe someday Describe your current practice: If doing an IMP already: How many years in IMP?  Select One 1 or Less 2-4 5 or More How many FTE providers are in your practice?  Select One Less than 1 FTE 1 FTE Greater than 1 up to 2 More than 2    How many staff?  Select One 0 Less than 1 FTE 1 FTE 2 FTE More than 2 FTEs What would you like help with? Special Dietary Restrictions: Questions/Comments: Acceptance of Terms and Conditions I have reviewed and acknowledge acceptance of the terms and conditions which includes the cancellation policy, insufficient check funds policy, and credit card terms.   *    Select Below Yes, I agree to the terms and conditions. Payment options include: Check or credit card If you would like a copy of this completed form, please print this page before you select "continue" and continue with the payment process.