201 6 C O R E Co nc e p t s ® Co ur s e R e g i s t r a t i o n F o r m (P a g e 1 o f 2 )
Register me to attend the CORE Concepts ® Course on:
August 12-15, San Diego, CA
This meeting is co-locating with the AADE16 Annual Meeting
Vis it www. di abetese duc ator . or g /cor e co nce ptsc our se f or ear ly r eg istr ati on dates , h ot el an d c our se deta ils.
Registrant Information (Please print clearly)
Name (First, Middle Initial, Last)
AADE Member ID #
Employer Name
Title
Address – Check preferred mailing address □ Home □ Work
City, State, Zip
Email Address (Required to receive confirmation)
Phone Number
I grant AADE the right to use photos which include me in promotion materials.
Course Registration Fees
I am not an AADE member, but I’d like to join now and take advantage of the member rate.
Early Registration Fee*
Registration Fee*
AADE Member
$545
$650
Nonmember
$745
$850
Non-Member with
$710
$790
AADE Membership (effective for one year from payment)
Do you wish to receive promotional materials/emails from Exhibitors?  Yes  No
By selecting NO, your name will be removed from pre and post mailing lists.
Is this your first time attending the AADE CORE Concepts?  Yes  No
Do you need special accommodations due to disability health concerns or physical challenges? If Yes, you will be contacted in July.
 Yes  No
What is your age group? Under 30
31-40
How did you learn about CORE Concepts?
 AADE E-Blast
 AADE Website
 AADE Registration Brochure
 Colleague/Co-Worker
 Industry Publication Ads
 Online Ads
 Post Card
 41-50  51-60
 60+
What is your primary reason for attending
CORE Concepts?
 Obtain CE Credits
 Networking with Colleagues
 Products and Services
 Professional Development
What is your practice setting?
 Self Employed
 Outpatient Diabetes Center
 University
 Hospital Pharmacy
 Long Term Care Facility/Skilled Nurse Facility
 Indian Health Services
 Home Care Services/Organization
 Other
What is your position?
 Staff/Clinical Care
 Clinical Specialist
 Consultant
 Pharmacist
 Patient Educator/diabetes Educator
 Administrator/Program Manager
 Coordinator/Other
 Other
Physician, Primary Care, Endocrinologist Office
 Hospital Inpatient/Hospital Outpatient Programs/Services
 Hospital Based Clinic
 Retail Pharmacy
 Managed Care/Commercial Health Plan (e.g. HMO)
 Military Base/Government Facility/VA Hospital
 Industry
 Public Health Community Center
 RN
License #
State
 APRN
License #
 NP
License #
State
 LPN
License #
 ANP
License #
State
 DNP
License #
 FNP
License #
State
 PNP
License #
 GNP
License #
State
 CNS
License #
 RD/LD License #
State
 RPh
License #
 PharmD License #
_ State
 CPNP
License #
State
NABP ePID#
 CRNP
License #
State
Birthday YYY/MM/DD:
 PA
License #
State
 Other (please list your credentials):
 LCPC  MSW  MD  DO  DPM  OD,LDO  CDE  BC-ADM  PT  OT  None
Registration Cancellation Policy
A refund of the registration fee less an administrative fee will be granted for all
written requests received by June 24, 2016. Written requests must be submitted
to [email protected]. No refund will be given after June 24, 2016. Refunds
will be granted to FULL PROGRAM registrations only, excluding Students.
No refunds will be granted for Students, guests, Single Day or Exhibit Hall &
General Session reg types.
Payment by Check: Must arrive no later than July 26, 2016.
Full registration payment must accompany your registration form.
Mail checks to:
AADE Registration
Department 4445, Carol Stream, IL 60122-4445
State
State
State
State
State
State
Credit Cards will be charged immediately.
Visa MasterCard  Discover  American Express
Card Number:
Name as it appears on the card
Expiration Date
Security Code
Signature
By signing this form: I authorize AADE's registration company to charge my credit card for the total payment due, acknowledge that the AADE registration
cancellation policies are in effect and grant AADE the right to use photos take at CORE Concepts which include me in promotional materials for future meetings.
Register by Phone: (800) 486-9644
Online: www.aade16.org
Email: [email protected]
Fax: (972) 349-7715