2014 Special Operations Medical Association’s Scientific Assembly and Exhibition USSOCOM REGISTRATION FORM

2014 Special Operations Medical Association’s
Scientific Assembly and Exhibition
December 8-11, 2014 Tampa Convention Center Tampa, Florida
USSOCOM REGISTRATION FORM
STEP ONE: Registrant Contact Information (Name only will appear on badges.)
Full Name:___________________________________________________________________________ Credentials:_______________________________
(Non-military; i.e. MD, DO, PA, NP, LVN, RN, PhD, PharmaD)
Organization:__________________________________________________________________________________________________________________
Address:______________________________________________________________________________________________________________________
City:_____________________________________________________ State/Province:_______________ Zip: __________________ Country:____________
Phone:_______________________________________Email:____________________________________________________________________________
STEP TWO: General Information
Special Needs (dietary/allergies/accessibility):
 Diabetic  Kosher  Vegetarian  Vegan  Gluten Free  Other_________________________________________
LIABILITY WAIVER AND EMERGENCY CONTACT
Please read and sign. I agree and acknowledge that I am undertaking participation in SOMSA events and activities as my own free and
intentional act and I am fully aware that possible physical injury might occur to me as a result of my participation in these events. I give this
acknowledgement freely and knowingly and that I am, as a result, able to participate in SOMSA events and I do hereby assume responsibility
for my own well-being. I am aware that photographs will be taken during the conference and may be published on the SOMA website or used
in promotional materials.
Signature:______________________________________________________________________ Date:___________________________________
REQUIRED: In case of emergency at the meeting, please contact (Name/Telephone/Relationship):____________________________________
______________________________________________________________________________________________________________________
 Please check here if you are a first-time attendee of the Special Operations Medical Association’s Scientific Assembly (SOMSA).
 Check here if you consent for your mailing address to be provided to our exhibitors for one time use.
STEP THREE: Demographics
Please select your
SOF Component
 USSOCOM
 USASOC
 NSWC
 AFSOC
 MARSOC
 JSOC
 SOCAF
 SOCCENT
 SOCEUR
 SOCKOR
 SOCNORTH
 SOCSOUTH
 NSHQ
Army
 18D
 68W-W1
 38B-W4
 68W
 68W-W2
 68J
 68R
 68S
 68T
 68X
 68Z
 68-other
 18-other
 38-other
 Other (SPECIFY):
Status
 Active Duty
 Reserve
 National Guard
___________________
Navy/USMC
 5392
 8403
 8427
 8401
 8402
 8404
 8406
 8409
 8425
 8432
 8493
 Other (SPECIFY):
USAF
 1T2X1
 4N0X1
 4A1XX
 4N0XX
 4E0XX
Military Unit (Current
Assignment)
________________________
________________________
________________________
___________________
Position / Title
________________________
________________________
________________________
Military Rank
 E1
 O1
 E2
 O2
 E3
 O3
 E4
 O4
 E5
 O5
 E6
 O6
 E7
 O7
 E8
 O8
 E9
 O9
 W1
 O10
 W2
 W3
 W4
 W5
STEP FOUR: Practical Labs – Monday, December 8
STEP SEVEN: Total Fees
Please ensure that the Labs you select do not overlap. Several of the same
Lab Sessions are being offered more than once during the day. These are
designated by a 1 or 2 after the title.
Military All Other
MedicsAttendees
 Difficult Airway – Basic 1 0800-1000  $50
 $100
 Wound Repair – Basic
0800-1000  $50
 $100
 Basic Point-of-Care Ultrasound 0800-1200  $50
 $50
 Regional Anesthesia – Ultrasound
Guided 0800-1200  $50
 $50
 Rescue Task Force Training 1
0800-1200  $50
 $100
 Procedural Sedation 1
0800-1200  $50
 $50
 Opthalmology 0800-1200  $50
 $50
 CONTOMS Medical Director
Course 0800-1700  $150  $150
 Prolonged Field Care (PFC)
Train-the-Trainer
0800-1700 $100  $100
 Working Canine Critical Care
Course 0800-1700  $100  $100
 Difficult Airway – Advanced 1 1000-1200  $50
 $100
 Wound Repair – Advanced 1000-1200  $50
 $100
 Difficult Airway – Basic 2 1300-1500  $50
 $100
 Dental Lab 1 1300-1500  $50
 $100
 Beyond on FAST Examination
1300-1600  $50
 $50
 Battlefield Medical Informatics 1300-1700  $0
 $0
 Advanced Point-of Care
Ultrasound 1300-1700  $50
 $100
 Rescue Task Force Training 2 1300-1700  $50
 $100
 Procedural Sedation 2 1300-1700  $50
 $50
 Difficult Airway – Advanced 2 1500-1700  $50
 $100
 Dental Lab 2 1700-1900  $50
 $100
*Please note that Labs, CME Fees, Guest Fees and Mess
Night fees are not reimbursable by SOCOM.
STEP FIVE: Full Conference Registration
3. 
By Mail: Mail completed registration
form and appropriate fees to:
SOMA Executive Office
P.O. Box 19489
Lenexa, KS 66285-9489
$__________Complimentary
 $300 Physician CME Fee
STEP SIX: Optional Activities & Guest(s) Fee
Opening Reception
#____ Guest(s) Ticket(s) @ $50
Guest Name(s)__________________________________________________
______________________________________________________________
Mess Night
$25 minimum donation per ticket. All proceeds go toward the SOMA
Scholarship Fund
 Attendee Ticket/donation  Guest(s) ticket(s)/donation $_________
$_________
Guest Name(s)__________________________________________________
Total Labs (Step 4)
$_________
Total Conference Registration Fees (Step 5)
$_________
OR
Total Optional Activities & Guest(s) Fee (Step 6) $_________
TOTAL PAYMENT ENCLOSED$_________
STEP EIGHT: Method of Payment
All funds MUST be submitted on a U.S. bank in U.S. funds.
SOMA does accept purchase orders. Simply complete and
submit your registration, an invoice will be sent within five to 10
business days. Tax ID 58-2108832
Check made payable to SOMA – Check #_______________
 Purchase Order
Charge payment to the following credit card:
 American Express  VISA  MasterCard  Discover
Credit Card Number
Expiration Date
Print Name on Card
SignatureDate
STEP TEN: Send in Your Registration

1.

2.
Online: Visit our website at
www.specialoperationsmedicine.org
and click on the Scientific Assembly link.
Via Fax: Fax completed registration
form with credit card payment
information to: 913.895.4652.
Courier service only:
18000 W. 105th St.
Olathe, KS 66061
Registrations will not be taken over the phone.
The deadline to register online, postmark or fax registrations
is November 14, 2014. After this date all registrations will
be processed on-site. Please bring your registration form and
payment directly to SOMSA.
Questions?
Call 913.895.4634 or email [email protected].
______________________________________________________________
Cancellation Policy: Written notice of cancellations received on or before October 27, 2014 will be fully refunded. Cancellations received from October
28 – November 14 will be refunded less a $50 processing fee. Cancellation requests received after November 14 will be considered on a case by case basis.
Substitution of registrants is allowed. All refunds will be processed after the Scientific Assembly.