Join us in Orlando, FL for a FACTSPre-Conference at AAPLOG-ACPeds "*" indicates required fields Name* Dr.MissMr.Mrs.Ms.Prof.Rev. Title (Mr./Mrs./Dr./etc.) First Last Degree Phone*Email We will send a confirmation email to this email address. If your email generates an error, please input it in the "Confirm your Email" field below.Confirm your Email*Please indicate your profession:*Family Physician (GP)OB/GYNHospital InternistSurgeonPhysician Assistant/AssociateNurse PractitionerNurseFertility Advisor/TeacherND/Naturopathic DoctorHealth or Wellness CoachCommunity SupporterStudent or Medical ResidentMidwife (CNM or CPM)OtherDescribe "Other"* Event Registration & InformationPre-Conference Registration - Please Select:* Medical or Health Professional - $125.00 Associate/Patient/Resident/Educator - $75.00 Student - $25 * Must be a full-time student enrolled in an accredited post-secondary program. ** Are you a paid FACTS member? Email us for a promo code: Members@FACTSaboutFertility.org This field is hidden when viewing the formSupport student scholarships I would like to donate to support student scholarships. Every $75 dollars donated enables one student to attend our conference.This field is hidden when viewing the formPlease indicate how many students you would like to supportFor every number you enter, it will multiply by $75 to get your total donation for student scholarships.Student Scholarship DonationThis field is hidden when viewing the formIf you are donating to support a specific student(s) please enter their name(s) belowHow did you hear about the pre-conference? FACTS Newsletter Email From Dr. Duane Friend or Family Member Medical Colleague or Organization Social Media Other Conference (please specify) Please put the name of the Friend or Family Member who told you about the conference.Please put the name of the Medical Colleague or Organization where you heard about the conference.Please SpecifyWould you like to share limited contact information with other conference attendees?Would you like to share limited contact information with other conference attendees? Yes No Consent I agree to the Refund Policy.If you are unable to attend the event, you may be eligible to receive a refund for registration fees, less a 20% administrative fee, if requested by November 1st. You will not receive a refund for other incurred expenses, including travel, accommodations, and/or other incidental costs. FACTS reserve the right to extend consideration for refunds in select circumstances at its sole discretion. Please note, each circumstance is unique, and election to offer any refund, discount, or credit in one instance does not create an obligation to do so in another. Consent I agree with the Photo / Video Consent.FACTS has official photographers and videographers for their meetings and events. Photos, videos, and audio taken may be used, without compensation, in future marketing, publicity, promotions, advertising and training activities for FACTS. By registering for this event, you agree to allow FACTS to use the photographs, video and audio-which may include you-in all media formats worldwide. Please note, that this event is held in a public space and, therefore we do not prohibit participants, exhibitors, sponsors, or news organizations from photographing, videotaping or recording audio. In addition, you agree to hold both FACTS harmless in the event that photos, video and audio are used that include your likeness on social media and/or future marketing materials.Have a Promo Code?FACTS members, don't forget to enter your member code below to save 20% on registration Total Billing InformationAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 Country Credit CardCard Details Cardholder Name
