www.csrc.org

48th Annual Convention

June 13-15, 2017 Harrah ’s Resort Southern California

Registration Form

PLEASE PRINT LEGIBLY Name ________________________________ RCP # __________ RN# ___________ AARC # ___________________ Home Mailing Address _____________________________________ City________________State____ZIP_________ Phone _______________________ email __________________________________ Best way to reach you: � Phone ☐ email Job Title/Employer ______________________________________________ (for event badge)

REGISTRATION FEES Include

Wednesday Breakfast & Lunch, Thursday Continental Breakfast All Social Activities Alcohol available at social events is no-host.

TUITION Ethics Class

Tues. June 13 9AM-12PM

Conference Only Mon. afternoon –

Wed. morning Does not include

ethics or workshops

Tues & Wed Wed & Thurs Tues. Only

Wed. Only

Thurs. Only

CSRC MEMBER 40 375 350 350 125 225 125

EVENT & CSRC MEMBERSHIP SPECIAL #1 NA 445 NA NA NA NA NA

EVENT & CSRC/AARC MEMBERSHIP SPECIAL #2 NA 534 NA NA NA NA NA

NON-CSRC MEMBERS 60 475 435 435 160 275 160

STUDENTS 20 110 110 110 50 100 50

GUEST-Non RCP - No CEUS given NA 110 110 110 NA NA NA

All Sputum Bowl Participants must be registered as Attendees of the conference. OUT OF STATE AARC MEMBERS MAY PAY THE CSRC MEMBER RATE

Ø Advance Registration deadline is June 2, 2017 Ø Registration after June 2, 2017 – Add $35.00 Ø Onsite registration only after June 2, 2017

TUITION (from above): $___________ ADD ON OPTIONS: $50 pre-registration ea, $65 after 6/2/17

• Pediatric Rockstar Assessment - 4ceu • Arterial Catheter Insertion - 4 ceu • Difficult Airway Management/Conscious Sedation - 4 ceu • ECMO (limited to 25)- 3 ceu • Lung Ultrasound (limited to 12) - 3 ceu

TOTAL FEES: $___________

Payment options: VISA, MC, AMEX, DISC

Checks-(payable to CSRC) Cash accepted onsite

DAILY REGISTRAION ONLY Circle Day(s) You Will Be Attending: Tues. June 13, 2017 Wed. June 14, 2017 Thur. June 15, 2017

Cardholder Name as it appears on card _____________________________________________ Credit Card # ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Exp. Date ___ ___/___ ___ CVV ___ ___ ___ ___ (VISA, MC & Discover – 3 digits from card back, AMEX – 4 digits from card front) Authorized Signature ___________________________________________

Refund policy: Refunds less $30 processing fee will be made if requested in writing prior to May 27, 2017. NO REFUNDS after May 27, 2017 Substitution Allowed with a 48 hour notice

Register On-Line @ www.CSRC.org FAX registration form to: CSRC (831)-763-2814 Mail registration from to: California Society for Respiratory Care 1961 Main Street, #246, Watsonville, CA 95076

For more information contact CSRC Office 888-730-2772 or office@csrc.org