7 1 S T A N N U A L M E E T I N GOF THE AMERICAN ASSOCIATION FOR THE SURGERY OF

TRAUMA AND CLINICAL CONGRESS OF ACUTE CARE SURGERY

SEPTEMBER 12–15, 2012 • KAUAI, HI • GRAND HYATT KAUAI

Each registrant must submit a separate form.

Attendee Information

FIRST MIDDLE LAST

PROFESSIONAL DEGREE(S) /DESIGNATION/CREDENTIALS POSITION/TITLE

INSTITUTION

PREFERRED MAILING ADDRESS

CITY STATE ZIP COUNTRY

PHONE FAX

E-MAIL (CONFIRMATION WILL BE SENT TO THE E-MAIL ADDRESS PROVIDED ABOVE.)

EMERGENCY CONTACT NAME

PHONE/CELL RELATIONSHIP TO ATTENDEE

MILITARY AFFILIATION: Active Reserve Guard Retired

Guest Information (if attending)–includes access to sessions, Poster Reception, and daily continental breakfast.

FIRST MIDDLE LAST

CITY STATE E -MAIL

Registration FeesFull Registration • Includes continental breakfast (Wednesday–Saturday), poster reception, and one banquet ticket.

Category Early Fee (On or before 8/13) Late Fee (After 8/13) Total

AAST Member $535 $595

Nonmember $605 $655

Nurse/Paramedical $490 $540

Other (medical personnel [non-MD] not listed) $490 $540

In-Training Fellow* $335 $335

Resident* $335 $335

Student* $170 $170

Guest/Spouse† Free (Banquet Ticket Extra) Free (Banquet Ticket Extra)

Daily Registration • Includes continental breakfast on registered day. Lunch sessions and the Friday banquet are additional.Check the day(s) you wish to register for.

Category Wednesday Thursday Friday† Saturday Total

Nurse/Paramedical $170 $170 $150 $20

Other (medical personnel [non-MD] not listed) $170 $170 $150 $20

In-Training Fellow* $110 $110 $90 $20

Resident* $110 $110 $90 $10

Student* $60 $60 $40 Free

Registration Fee Subtotal:

THREE EASY WAYS TO REGISTER! Please choose one method. Online: www.aast.org Fax: 312-202-5003Mail: AAST Registration Services, c/o American College of Surgeons 633 N. Saint Clair St., Chicago, IL 60611

* Requires verification letter from department chairman or program director. Online registration not available; please submit registration form with letter by fax or mail.† Friday banquet is not included with Guest/Spouse or Friday daily registration. Please purchase a banquet ticket ($170) if you would like to attend.

Early registration deadline:MONDAY, AUGUST 13

7 1 S T A N N U A L M E E T I N GOF THE AMERICAN ASSOCIATION FOR THE SURGERY OF

TRAUMA AND CLINICAL CONGRESS OF ACUTE CARE SURGERY

SEPTEMBER 12–15, 2012 • KAUAI, HI • GRAND HYATT KAUAI

Lunch Sessions

Please rank the following in the order of preference. $50/each

If you are a lunch session moderator, please check here to receive your complimentary lunch ticket.

Friday Evening Banquet

Additional Banquet Tickets

Included with full registration. Attire is luau, resort, or business casual.

Please indicate if you plan to attend, as the event will be ticketed. Yes, I would like to attend.

Adult Banquet Tickets: $150/each ______ Qty.Jr’s (13-20 years old): $130/each ______ Qty.Kids (5-12 years old): $90/each ______ Qty.

Optional Breakfasts

Resident, Student and In-Training Fellow BreakfastWednesday, September 12

Free

International Attendee BreakfastFriday, September 14 (for all international attendees only)

Free

New Fellow BreakfastSaturday, September 15 (for 2010 and 2011 new members only)

Free

Registration Fee (from previous page):

TOTAL AMOUNT DUE:Americans with Disabilities ACTPlease indicate if an ADA accommodation is required. If required, an AAST staff person will contact you.

Audio Visual Mobile Other _______________________________________

Check here if you or your guest has a dietary restriction.

Please specify _____________________________________________________________

PaymentPayment must accompany registration. Registrationcannot be confirmed without payment. Purchaseorders are not accepted. AAST Tax ID : 36-2985865.

Fees payable in U.S. funds to AAST.

Check (enclosed)

American Express MasterCard VISA

CREDIT CARD NUMBER

EXPIRATION DATE

CARD HOLDER NAME

SIGNATURE

CARD HOLDER BILLING ADDRESS

ConfirmationConfirmations will be sent via e-mail, fax, or mail to all registrants. Please ensure legibility prior to faxing or mailing, and include all pages of the registration form.

Cancellation PolicyRequests for refunds must be made in writing and received on or before Friday, August 31, 2012. There is a $50 processing fee for all refunds and returned checks. Cancellations and registrations postmarked after the deadline date will not be eligible for refunds.

Conference attendee substitution is permitted and will be dealt with on a case-by-case basis. AAST reserves the right to cancel any regularly scheduled session prior to the start of the meeting.

Registration questions?Please contact AAST Registration Services at registration@facs.org or 312-202-5244.

Lunch Session Subtotal:

Friday Evening Banquet Subtotal:

Wednesday, September 12 11:50 am – 1:15 pm

___ Complex Hernia/Abdominal Wall Reconstruction

___ Focused Echo in the Trauma ICU: Expensive toy or valuable tool

___ How to take care of a kid's injured brain

___ Injury Prevention Toolkit: It's as Easy as 1-2-3

___ Challenging Penetrating Chest Trauma Cases: An Interactive Session

___ Journal of Trauma: How to Publish

Friday, September 1411:30 am – 1:00 pm

___ The trauma patient in extremis___ Laparoscopic Approach to Acute

Surgical Problems___ Contemporary Pre-Hospital Military

Medical Evacuation Platforms: Scoop and Run, Stay and Play or Scoop and Play?

___ Management of Bleeding Pelvic Fractures across all ages.

___ A Night on Trauma Call-A Case Based Interactive Learning Session

___ Building Your Research Portfolio/The Successful Surgical Researcher

Early registration deadline:MONDAY, AUGUST 13

AAST will be providing AMA PRA Category 1 CreditsTM with a self-assessment component as required for the fulfillment of Part 2 of the American Board of Surgery Maintenance of Certification (MOC) Program to Physicians.