Colorado Mammography Society Conference

CONFERENCE REGISTRATION COLORADO MAMMOGRAPHY SOCIETY April 8, 2017 St. Joseph Hospital 1375 East 19th Avenue Denver, Colorado 80218

Registration forms must be post-marked by March 24, 2017 to receive pre-registration discount. Space is limited, so please consider registering early. PRE-REGISTRATION COST: REGISTRATION COST: Post Marked with payment by March 24, 2017 After March 24, 2017 MEMBERS: $95.00 MEMBERS: $125.00 NON-MEMBERS: $125.00 NON-MEMBERS: $155.00 Please make checks or money orders payable to the Colorado Mammography Society. (NO CASH ACCEPTED BY MAIL OR ON SITE). Registration includes continental breakfast and lunch. Space is limited. Please check CSRT website if not pre-registering, if full. The Colorado Mammography Society is sensitive to your nutrition requirements. While not all of the menus selected may meet your entire dietary need, there will be food items available for you to satisfy your appetite. As a reminder: Please bring an extra sweater or wrap as temperature variability changes in the meeting room throughout the day. Name and Credentials to list on your conference Certificate (e.g. R.T. R. M.)

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Address______

City______State______Zip______

Phone(s) (Home/Cell) ______(W) ______

E-Mail______

Employer______

Fill in the appropriate space below for registration confirmation:

RELEASE AND DISCLAMER OF LIABILITY The undersigned, intending to engage in any activity of the COLORADO MAMMOGRAPHY SOCIETY, does hereby hold harmless the COLORADO MAMMOGRAPHY SOCIETY, and all officers, members and agents thereof, from any personal injury and/or property damage or loss the undersigned may incur, both during participation in said activities and during travel to and from the places where the activities take place.

DATE ______SIGNATURE______

Application for any attendance will not be accepted without this signed release.

Mail Conference Registration forms to: Jill Cossaboom, Education Coordinator 9825 Kings Canyon Drive Peyton, Colorado 80831 [email protected] Refund/Returned checks policy: Requests for refunds must be submitted in writing and post-marked by March 24, 2017 a $25.00 processing fee will be deducted from the registration fee. No partial or full refunds will be given after March 24, 2017. If you cannot attend, you may send a substitute; you must notify a CMS Board member prior to the conference. In the event the CMS conference is cancelled, refunds will be issued. Returned checks from a facility will require that the conference attendee pay for the conference and then seek a refund from their facility.