I will be attending the 2010 GSD Annual Meeting as a

GSD Member/GSD Applicant/ Resident Physician in a GA Training Program (NO Registration Fee*)

Physician / Non-GSD Member residing in GA, NC, SC, TN, AL or FL ($150 Registration Fee)

Resident Physician in a NON-GA Training Program ($150 Registration Fee)

Physician / Non-GSD Member residing in any other state not listed above ($300 Registration Fee)

Name (req.)

Practice/Company Name

Address

City, State  Zip

E-mail (req.)

Office Phone

Mobile Phone

Fax

Guests will be accompanying me

Spouse/Guest and Children's Names (please include ages of children):

I/We will attend the Friday evening Cocktail Reception

Number attending

I/We will attend the Saturday evening Family Luau (dinner and entertainment  included)

NOTE: Each registration includes 2 adults and 2 children to the Luau.  Additional tickets may be purchased, $75/adult, $30/child (age 4-12)

Number attending

Make your accommodations reservation at the Ritz Carlton, Amelia Island by calling  800-241-3333 and book under the Georgia Society of Dermatologists room block. The room block EXPIRES May 3.

When you submit this form you will be taken to a payment page to complete this registration.

*GSD Members receive free meeting registration IF their 2010 dues are paid in full.