September 14-16, 2018 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 Monday, September 10th at 9:00 a.m. After September 10, registration will only be available onsite at the conference venue. Registrant InformationName* First Last DegreePreferred First Name for BadgePractice name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Phone*Email* Dietary NeedsIf you have any dietary needs or requests for the conference organizers, please state them in the box below or contact Debra Alderman at 206-956-3650 or email: debra@wsma.orgProfessional CategoryRheumatologistNon-rheumatologist physicianNon-physician healthcare professionalPractice Manager/Administrative ProfessionalResidentFellowMedical StudentNon-physician healthcare professionals, are you a nurse, PA, or other (please specify)If you are a resident, fellow, or medical student, please state where you currently are in trainingIndustry RegistrationIf you are interested in attending the meeting, please contact Debra Alderman at debra@wsma.org or 206.956.3650. WRA MembershipJoin the Washington Rheumatology Alliance and attend the 2018 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 attendees.)WRA MembershipWRA 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. Yes, I would like to pay my $45 dues for 2018 which entitles me to the member rate for conference registration.I’ve previously paid my 2018 duesNo, I do not want to pay for WRA member dues at this time.Conference Registration Details12th Annual Conference Registration RateMember Conference Registration ($45)12th Annual Conference Registration RateNon-member Conference Registration ($150)Resident/Fellow/Medical Student Registration (free)Optional pre-conference Coding and Reimbursement SeminarFriday afternoon, 9/14/18, 1-5 p.m. Cost is an additional $25 per person; free for residents/fellows. Coding seminar registration fee - $25 Resident/Fellow - No Charge Coding seminar registration fee - $25 Price: $25.00 Resident/Fellow - No Charge Price: $0.00 Conference GuestsConference fee for spouses/guests/children is $25 per person.This year, guests’ meals throughout the weekend will be covered by the WRA master bill and not added to your individual hotel bill.Please indicate the number of guest tickets you would like to purchase below.12th Annual Conference Registration - Spouse/guest/child @ $25/ticketNumber of ticketsOne guest - $25.00Two guests - $50.00Three guests - $75.00Four guests - $100.00Guest InformationPlease use the box below to list your guests’ names and relationship (such as spouse, child, etc.) Please do not buy a spouse ticket for a conference participant. Each participating spouse should fill out a separate registration form. 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