pre-registration form - ACG 2015 Annual Scientific Meeting

Registering for ACG 2015 is easy.
You can register online, by fax, or by mail.
ONLINE
www.acgmeetings.gi.org
FAX 301-263-9025
Step 1 • Contact Information
Provide your contact information (including email
address) on the Registration Form.
Step 2 • Course Selections
To register, choose one of the educational programs
under your corresponding registration category. You
may also select one or more of the optional programs
offered on Friday, October 16. Please circle the Friday
Program(s) you would like to attend.
Note: If you select the 3-day Clinical Review, you do
not need to register for the GI Pathophysiology Course
or the What’s New in GI Pharmacology Course.
Registrants of the Postgraduate Course and the Annual
Scientific Meeting may choose to receive either a
printed copy of the meeting syllabus or a PDF of the
syllabus on a USB drive. There is a separate charge to
purchase both the USB version and the printed version
of either syllabus.
Pre-registration deadline:
Friday, October 9, 2015
For those sending registration via
U.S. mail, please postmark your registration
no later than Monday, September 28, 2015.
MAIL
American College of Gastroenterology
6400 Goldsboro Road, Suite 200
Bethesda, MD 20817-5842
Step 3 • Optional Learning Luncheons and
Breakfast Sessions
If you’ve selected the Postgraduate Course, you have the
option of attending up to two of the 24 Postgraduate Course
Learning Luncheons (one each day) to be offered. The cost is
$75 each. Learning Luncheons are offered on Saturday and
Sunday, October 17 and 18. You may choose one Learning
Luncheon each day. Learning Luncheons are optional. Since
Learning Luncheons fill up fast, please indicate your top five
choices for each day by numbering them 1-5. We will make
every effort to accommodate your top choice.
If you signed up for the Annual Scientific Meeting, you have
the option of attending up to three of the 16 Annual Scientific
Meeting Breakfast Sessions offered on Monday, October 19,
Tuesday, October 20, and Wednesday, October 21. The cost is
$60 each. A syllabus on USB containing all ACG 2015 Breakfast
Session handouts will be provided to attendees registered for
any Breakfast Session. You may choose one Breakfast Session
each day. Breakfast Sessions are optional. Since Breakfast
Sessions fill up fast, please indicate your top five choices for
each day by numbering them 1-5. We will make every effort
to accommodate your top choice.
Step 4 • Additional Offerings
ACG offers additional programs or materials to certain
attendees.
•Fellows-in-training may sign up for the Trainees luncheon
on Sunday, October 18. The cost is $35. This event is
available only to GI fellows-in-training.
Step 5 • Payment
Registration selections are now complete. If you choose
to mail or fax the registration form, please complete the
payment information on the form and sign the form.
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ACG 2015 Registration Form
Pre-registration will remain open until Friday, October 9, 2015. For those sending registration
via U.S. mail, please postmark your registration no later than Monday, September 28, 2015.
Mail to: ACG, 6400 Goldsboro Road,
Suite 200, Bethesda, MD 20817-5842
Fax to: ACG at 301-263-9025.
Fax with credit card number and signature.
Web: Register at www.acgmeetings.gi.org.
Cancellation: Written notice of cancellation
and requests for refunds must be received by
the College’s office by September 25, 2015.
After this day, no refunds will be possible.
Please complete sections 1-5.
Please print clearly.
Registration cancellations are not accepted by
telephone. An explanation must be provided in
writing. There will be a $50 administrative fee
assessed for cancellation of any paid event.
Refunds will be issued after the meeting. See
Cancellation Policy on page 34.
ADA Compliance: Attendees of the ACG
Annual Meeting who need additional
reasonable accommodations or who have
special needs should contact the ACG office
at 301-263-9000 no later than September 25.
1. personal Information
First name
Last Name
MUST circle all that apply: MD* DO* PhD
Mailing address
Home address
PANP RN
LPN PharmD Other
*Please enter your 10-digit NPI number (required if U.S. physician)
Look up your NPI number at npinumberlookup.org.
Work address
City
State/Province
Zip / Postal Code
Phone
Country
Fax
Email (required for meeting confirmation) Spouse / Guest name, only if attending meeting
2. Registration fees
I am currently an ACG member.
My application* for membership is attached.
I have registered below at the member rates.
(For membership information or to download
a membership application, visit www.gi.org.)
*
Registration will not be processed without
membership application.
I am an ACG 2015 presenter:
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Circle fee(s) based on attendee type
a
PG Course and Annual Meeting, Oct. 17–21
PG Course Onlya, Oct. 17–18
Annual Meeting Only, Oct. 19–21
3-day Clinical Review, Oct. 16–18, includes PG Coursea,
GI Pathophysiology, and GI Pharmacology
3-day Clinical Reviewa PLUS Annual Meeting, Oct. 16–21
ACG MEMBERS
NON-MEMBERS
$425 $425 $0 $600 $0 $0 $0 $200 $275
$275
$0
$450
$750
$550
$300
$750
$200 $200
$0
$425 $575
$500
$150
$725
$575
$500
$150
$725
$600 $200 $450
$850 $425 $800
$800
$200 $200 $275 $150
$395 $160 $160 $0
$150
$200 $175
$175
$200
$150
$200
$225 $225 $300 $175
$495 $225 $225 $300
$175
$250 $225
$225
$300
$175
$250
$225
$225
$300
$175
$250
Optional Friday Programs, October 16
GI Pathophysiology; half-day/am (included in 3-Day Clinical)
GI Pharmacology; half-day/pm (included in 3-Day Clinical)
Practice Management; full day
GI Recertification; half-day/pm (includes 10-point SAPMOC)
ASGE Postgraduate Course; full day
a
b
Includes 10-point PG+MOC module.
Resident/Trainee non-member registrations will
not be processed without a letter from the Program
Director verifying status.
Postgraduate Course attendees
Please indicate Syllabus preference.
Print version only........ FREE
USB drive only............ FREE
Print and USB................$30
2015ADV
Annual Scientific Meeting attendees
Please indicate Syllabus preference.
Print version only........ FREE
USB drive only............ FREE
Print and USB................$30
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3. optional sessions
Learning Luncheons No refunds after September 25, 2015.
$75 – Saturday Learning Lunch – pg course registrants only
11:55am – 1:10pm, October 17, 2015
Select top 5
choices and
number them
1, 2, 3, 4 or 5.
Rectal Problems: ‘Roids, Fissures, Tags, Dysfunction
Refractory IBD Patient
Current Indications and Use for EUS in 2015
Diverticular Disease—Another Chronic Colitis?
Ugh! Liver Disease in Pregnancy
Incorporate Quality Initiatives Into Your Practice
Esophageal Function Testing in Practice
Practical Pearls in the Care of the IBD Patient
Liver Lesions: Evaluation and Management
Flat, Large Colon Polyp Diagnosis, Management
Luminal Neuroendocrine Tumors
EMR, ESD and Advanced Polypectomy
LL1
LL2
LL3
LL4
LL5
LL6
LL7
LL8
LL9
LL10
LL11
LL12
BREAKFAST SESSIONs No refunds after September 25, 2015.
$60 – Monday Breakfast – annual meeting registrants only
6:00am – 7:00am, October 19, 2015
Select top 4
choices and
number them
1, 2, 3 or 4.
$60 – Tuesday Breakfast – annual meeting registrants only
6:00am – 7:00am, October 20, 2015
Select top 5
choices and
number them
1, 2, 3, 4 or 5.
Anorectal Disorders
Large, Flat or Hiding: Know Your Enemy
Gastroenterology and the Law
Complex Cases in Pancreatology
Complementary and Alternative Therapies
Practical Approach to the Liver Zebras
Celiac Disease: What Is New on the Horizon?
The Ever-changing Waves of Esophageal Motility
$75 – Sunday Learning Lunch – pg course registrants only
12:20pm – 1:35pm, October 18, 2015
Select top 5
choices and
number them
1, 2, 3, 4 or 5.
Non-Achalasia Esophageal Motility Disorders
Decision Making in Hereditary Colon Cancer
Managing IBD Through Childbearing Years
Screening Your IBD Patient for Colon Cancer
Impact of Public Policy Changes on the GI Practice
Management of Ascities and Fluid Overload
Capsule Endoscopy: What Is On the Horizon?
Management of Fecal Incontinence
Endoscopic Approaches to Perfs, Fistulas, Leaks
Pelvic Floor Dysfunction
How Can I Increase My Adenoma Detection Rate?
Managing Benign, Malignant Biliary Strictures
LL13
LL14
LL15
LL16
LL17
LL18
LL19
LL20
LL21
LL22
LL23
LL24
MONA
MONB
MONC
MOND
Not All Colitis Is Created Equal
What the GI Needs to Know About Surgery for IBD
Bariatric Endoscopy
Applying the Gut Microbiome to Your Practice
TUEE
TUEF
TUEG
TUEH
TUEI
TUEJ
TUEK
TUEL
$60 – Wednesday Breakfast – annual meeting registrants only
6:00am – 7:00am, October 21, 2015
Select top 4
choices and
number them
1, 2, 3 or 4.
Controversial Debates in Endoscopy
Small Bowel, Large Problem
What Your IBD Patient Really Wants to Know
Hepatitis B: The Forgotten Virus
WEDM
WEDN
WEDO
WEDP
NOTE: While space is limited for the Learning Luncheons and the
Breakfast Sessions, we will make every effort to accommodate
your top choice. Register early for best selection.
4. ADDITIONAL OFFERINGS
I am registering for a breakfast
and/or lunch, and require a:
$35 – Trainees Luncheon
12:20pm – 1:35pm, October 18, 2015
You may not register for a Sunday Learning Luncheon if you
register for the Trainees Luncheon. See page 23 for details.
No refunds after September 25, 2015.
Vegetarian meal
Kosher meal
Gluten free meal
5. payment
Pay by check. Make checks payable in U.S. funds to ACG.
Pay by credit card:
VISA
MasterCardAMEX
Subtotal section 2:
Credit Card #Exp. Date
Subtotal section 3:
Subtotal section 4:
Name on Card
3 or 4 digit
security code
TOTAL DUE:
Signature
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