"*" indicates required fields September 22-24, 2023 Sleeping Lady Mountain Resort Leavenworth, WA Participant Registration Form Industry exhibitors should not use this form to register. More information about industry opportunities at this meeting can be found on the Exhibitor Page. Online registration will be available until 4pm, Monday, September 18. After September 18, registration will only be available onsite at the conference venue.Registrant InformationName* First Last Credentials (MD, DO) Preferred First Name for Badge (If Different than Above)If you use "Bob" instead of "Robert" or a middle name you would prefer to be on your badge, put it here. Otherwise, leave it blank. Preferred PronounsA pronoun is a word that substitutes for a noun; in this case, a word that substitutes for your name. We want to know what to call you! Examples: he, she, they Practice name* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone*Email* Professional Category* Rheumatologist Non-rheumatologist physician Non-physician healthcare professional Practice Manager/Administrative Professional Resident Fellow Medical Student Industry Representative (If not exhibiting) Speaker Non-physician healthcare professionals: are you a nurse, PA, or other? Please specify below.If you are a resident, fellow, or medical student, please state where you currently are in training:MembershipWRA Membership*WRA membership (which is for individuals, rather than practices), is open to rheumatologists and other healthcare providers as well as medical practice staff. WRA membership is not open to industry-employed individuals. Please select an option below for applicable conference registration rates. Yes, I Would Like to Pay My 2023 WRA Membership Dues With My Registration. No, I Have Previously Paid My 2023 WRA Membership Dues No, I Do Not Want to Pay For WRA Member Dues at This Time. WRA Membership Category Rheumatologist Non-rheumatologist physician Non-physician healthcare professional Practice Manager / Admnistrative Professional Resident Registration SelectionIndustry RegistrationIf you are interested in attending the meeting as an exhibitor, please contact the WRA executive at jena@wsma.org or 206.956.3621. WRA MembershipJoin the Washington Rheumatology Alliance and attend the 2024 Annual Meeting at the discounted member rate! (Note, industry-employed professionals are not eligible for membership in the WRA but are welcome to participate in the conference – either as exhibitors representing their companies or as a non-member attendee.)Conference Registration Details WRA member rate: $45 Non-member rate: $150 Resident/Fellow/Medical Student: $0 Industry Representative (not exhibiting) - Limit One for Company: $1500 16th Annual Conference Registration Rate* Conference Registration Conference GuestsConference fee for spouses/guests/children is $25 per person. Please indicate the number of guest tickets you would like to purchase below.16th Annual Conference Registration - Spouse/guest/child @ $25/ticketNumber of ticketsOne guestTwo guestsThree guestsFour guestsGuest InformationFirst NameLast NameRelationship (spouse, child, etc.)Dietary Needs Add RemoveCoupon TOTAL CREDIT CARD American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name Δ
