2023 IAFP Annual Convention Registration COD ONLY Question Title * 1. AAFP ID Question Title * 2. Full Name Question Title * 3. Nickname for Badge Question Title * 4. Designation (Select all that apply) MD DO Residency graduate in 2020, 2021, 2022, or 2023 Current Resident Current Student Other (please specify) Question Title * 5. Are you a Fellow of the AAFP (FAAFP)? Yes No Question Title * 6. City, State Question Title * 7. Phone Number Question Title * 8. Email Question Title * 9. I will be present for the following meals Friday Congress of Delegates Lunch Saturday Congress of Delegates Lunch Question Title * 10. I am planning the following hotel accommodations I plan to stay at the French Lick Hotel I plan to stay at the West Baden Hotel I plan to stay at another hotel I do not plan to make hotel accommodations Question Title * 11. Special Needs Lactation Room Vegan Vegetarian Gluten Free None Question Title * 12. CONSENT TO USE OF PHOTOGRAPHIC IMAGES: Registration and attendance at, or participation in, IAFP meetings and other activities constitutes an agreement by the registrant for IAFP use and distribution (both now and in the future) of the registrant or attendee’s image or voice in photographs, videotapes, electronic reproductions, and audiotapes of such events and activities. Yes, I consent to use of photographic images No, I do not consent to use of photographic images Question Title * 13. CANCELLATION POLICY: You may cancel without penalty if cancellation request is received up to one week prior to the start of the conference. Due to financial obligations incurred by the IAFP, refunds or credits may not be issued for cancellation requests received less than one week prior to the start of the event. I agree to the cancellation policy Done