NASMDA Registration 2007 Name:___________________________________College:_______________________________
Address:_______________________________________________________________________
Contact Information: Home Tel:____________ E-Mail:____________________________
Office Tel:____________ Fax #:_____________________________
Number of participants playing: Golf____ Tennis ____ Number of Vegetarians______ Number of persons in your party interested in visiting the local area attractions_________ Name of Attendees | Age of Attendees | | 1 | | | 2 | | | 3 | | | 4 | | | 5 | | Per Adult & Youth 10 yrs or older Per Child 3-10 years Children under 3 Total
Package A $ 285x ___ = $____ $ 185 x ___ = $_____ FREE $_______
Package B $ 235x ___ = $____ $ 145 x ___ = $_____ FREE $_______
Package C $ 180 x ___ = $____ $ 100x __ = $_____ FREE $_______
Guests $ 100 Per Person /per day $ 50 Per Child/per day $_______
Package descriptions available on the back of this form. (ANYONE OTHER THAN PARENTS AND CHILDREN ARE CONSIDERED GUESTS.) Medical and Dental Students & those in Residency and Fellowship training programs are Discounted 50% off the package price
Total of All packages------------------------------------------------------------------------------ $_______
Membership Fee: - Annual Membership: $100/year $_______
- Life Membership: $1000 $_______
- Resident: $50/year $_______
CME Fee: - $100 Per person Physician / Dentist (5 hours of CME) $_______
- Medical / Dental students-No Registration fee and no CME charge FREE
Registration Postmarked after 9/5/2007 will be Charged a Late Fee of $25 $_______ Grand Total----------------------------------------------------------------------------------------- $_______ Please Make Check Payable to: NASMDA Mail to: Baljit Singh Sidhu, MD 13225 Riversbend Boulevard, Chester, VA 23836
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