Registration Form

* Denotes Required Field

* Name (Last, First, MI):

* Company Name:

* Office Phone:

Mobile Phone:

Fax:

* Email Address:

* Confirm Email Address:

* Mailing Address:

* City:

* State/Province:

* Zip Code:

* Country:

Accompany Person(s) Name(s):
(include age if child)

 Age
Age

Registration Fees (select one per registrant): Includes all Breakfasts, Social Functions and Coffee Breaks
NO LONGER AVAILABLE After 1 Oct After 1 Jan FEES
Physician

$495.00

$550.00

$600.00
 $
Physician Hawaii (Kama'aina) +

$300.00

$350.00

$500.00
 $
Physician Dermatology Resident +

$200.00

$250.00

$300.00
 $
+ Proof Required
Physician / One (1) day pass

$200.00
 Note: On-site add $25.00 $
Physician / Two (2) day pass
(must be two consecutive days)

$300.00
 Note: On-site add $25.00 $
Date(s): /
R.N P.A. Office Personnel
Note: RN's must be accompanied by a physician.

$300.00

$350.00

$400.00
 $
Spouses / Guests

$200.00

$250.00

$300.00
 $
Children 10 - 18

$150.00

$200.00

$250.00
 $
Children under age of 10 Complimentary
Exhibitor-Additional 2nd or 3rd person/each

$300.00

$300.00

$350.00
 $

Lunch with Faculty:  

Lunch with Faculty is hosted daily throughout the Conference at no additional charge. Registration Is Required. Please check below the dates on which you plan to attend.

Time

Will Attend
Melanoma Update 2009

Monday
12:15 - 1:45 PM
 Yes
Psoriasis Update 2009

Tuesday
12:45 - 2:30 PM
 Yes
Pediatric Procedural Dermatology

Wednesday
12:20 - 1:10 PM
 Yes
Laser Demonstrations

Thursday
12:30 - 2:45 PM
 Yes

Workshops:  

ADVANCE REGISTRATION REQUIRED / NO FEE *

Time

Will Attend
Is Dermoscopy Becoming the Standard of Care in Dermatology?

Monday
2:00 - 5:00 PM
 Yes
Chemoprevention Live Patient Demonstration Workshop:
Treating Actinic Keratoses

Tuesday
3:00 - 5:00 PM
 Yes
Management of Venous Diseases:
Lecture and Live Patient Demonstration Sclerotherapy Workshop

Wednesday
3:00 - 5:00 PM
 Yes
WINE + CHEESE RECEPTION
Controversies in Laser Medicine

Thursday
3:00 - 4:30 PM
 Yes
Lunchtime Workshop:
General Injection Toxins and Fillers - Session 1

Friday
12:30 - 1:45 PM
 Yes
General Question and Answer Session

Friday
1:45 - 2:00 PM
 Yes
Afternoon Workshop:
General Injection Toxins and Fillers - Session 2

Friday
2:00 - 3:00 PM
 Yes
Small Group Training Sessions:
Toxins & Fillers by Product

Friday
3:00 - 4:00 PM
 Yes
Small Group Training Sessions:
Toxins & Fillers by Product (repeat session)

Friday
4:00 - 5:00 PM
 Yes

* Due to industry support, the workshop fees have been waived.

Due to industry support, the workshop fee of $125.00 has been waived. Advance Registration Required.
REGISTER EARLY. Workshop space is limited based on first-come, first served basis. On-site subject to availability.
NOTE: Maui Derm reserves the right to cancel any workshop for lack of attendance.
* Proof required for Kama’aina and Dermatology Residents.

Payment Information:  

Cardholder Name:

Payment Type:

Card Number:

Card Expiration Date:

CID:

Payment Amount:

 $

Make Checks Payable To:

 HTC INTL

Send To:

 HTC INTL
333 N. Michigan Ave., #1820
Chicago, IL 60601



For any questions, please contact HTC INTL at 312-263-1007 or via email bjohnson@htcintl.com.

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