Single Topic Symposium / Postgraduate Course / Annual Meetings of NASPGHAN, APGNN & CPNP 2018 REGISTRATION FORM

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1 Single Topic Symposium / Postgraduate Course / Annual Meetings of NASPGHAN, APGNN & CPNP 2018 REGISTRATION FORM Early-Bird Registration Deadline: August 28, (To receive Early-Bird rates, envelopes must be postmarked no later than August 28, or standard rates will apply.) After August 28 th, Standard Rates apply and fees for Single Topic Symposium, Postgraduate Course, and Annual Meetings increase by $50 each per category. After October 4, rates increase again to on-site rates and fees for Single Topic Symposium, Postgraduate Course and Annual Meetings rise an additional $50 each per category. Register online at meeting Fill in below information with a complete address indicating where registration/meeting material should be mailed. Please print clearly. First Name Last Name Address City State Zip Country Phone Fax (Required) Dietary Restrictions Survey Question: In the future, do you favor increasing the number of days for the NASPGHAN Annual Meeting to allow for more oral research and state of the art presentations? Yes No NASPGHAN Single Topic Symposium, Wednesday, October 24, Check your member type Early Bird Rates Standard Rates After 10/4/18 Deadline 8/28/18** Deadline 10/4/18 Member $250 $300 $350 Non-Member $425 $475 $525 Trainee/Fellow Member $150 $200 $250 Non-Member Trainee $200 $250 $300 Psychologist Member $150 $200 $250 Non-Member Psychologist $200 $250 $300 Student/Resident $75 $125 $175 APGNN Member $150 $200 $250 Non-Member Nurse $200 $250 $300 CPNP Member $150 $200 $250 Non-Member Nutritionist $200 $250 $300 Allied Health Professional $200 $250 $300 **To receive Early-Bird rates, envelopes must be postmarked no later than August 28.

2 Single Topic Symposium Breakout Sessions (Select Two): You must be registered for the STS to attend. Each attendee will have option to pick two (2) 60-minute sessions. Indicate Choices Breakout Session 1 1. Hands-On Demonstrations: Hands-on Esophageal Manometry and Hands-on ph Impedance 2. Next steps in the pediatric esophagus- POEM, esophageal topography, and more 3. Psychological treatment options in functional GI disorders 4. Multidisciplinary team building 5. From bench to bedside: Navigating an academic career in pediatric gastroenterology and motility 6. Special session: Manometry tracings, difficult cases in GI motility (In Spanish) Breakout Session 2 7. Hands-on Demonstrations: Hands-on Anorectal Manometry (ARM) and Hands-on Colonic Manometry (CM) 8. Cecostomy, Ileostomy, Colostomy 9. Dietary and Non-pharmacologic management options for pain/ibs 10. Transit studies: Methods and interpretation 11. Anorectal and colonic manometry: Difficult cases (In Spanish) NASPGHAN Postgraduate Course, Thursday, October 25, Check your member type Early Bird Rates Standard Rates After 10/4/18 Deadline 8/28/18** Deadline 10/4/18 Member $325 $375 $425 Non-Member $500 $550 $600 Trainee/Fellow Member $200 $250 $300 Non-Member Trainee $250 $300 $350 Psychologist Member $200 $250 $300 Non-Member Psychologist $250 $300 $350 Student/Resident $75 $125 $175 APGNN Member $200 $250 $300 Non-Member Nurse $250 $300 $350 CPNP Member $200 $250 $300 Non-Member Nutritionist $250 $300 $350 Allied Health Professional $200 $250 $300 **To receive Early-Bird rates, envelopes must be postmarked no later than August 28. NASPGHAN Postgraduate Course Learning Lunches (Select One) Thursday, October 25, You must be registered for the PG Course to attend a Learning Lunch. Learning Lunches: $25 Indicate top three choices below, indicated by #1, #2, #3. 1. The complicated endoscopy (upper, lower, high risk patients) 2. Medical and psychological treatment of vomiting 3. Management of irritable bowel syndrome 4. Treat to Target 5. Severe Acute Colitis 6. Nutritional and medical management of complicated pancreatitis 7. Evaluation/Management of the patient with liver failure 8. EoE complicated cases 9. Weight management Medical/Surgical Approach

3 Annual Meetings of NASPGHAN, APGNN, and CPNP, Thursday evening, Friday and Saturday, October 25-27, Your Registration will allow you access to all Annual Meeting sessions of NASPGHAN, APGNN and CPNP. Check your member type Early Bird Rates Standard Rates After 10/4/18 Deadline 8/28/18** Deadline 10/4/18 Member $350 $400 $450 Non-Member $525 $575 $625 Trainee/Fellow Member $200 $250 $300 Non-Member Trainee $250 $300 $350 APGNN Member $200 $250 $300 Non-Member Nurse $250 $300 $350 CPNP Member $150 $200 $250 Non-Member Nutritionist $200 $250 $300 Psychologist Member $200 $250 $300 Non-Member Psychologist $250 $300 $350 Student / Resident $75 $125 $175 Allied Health Professional $225 $275 $325 **To receive Early-Bird rates, envelopes must be postmarked no later than August 28. Meet the Professor Breakfast Sessions. (Select One per day ) Friday, October 26 and Saturday, October 27, 2018 You must be registered for the Annual Meeting of NASPGHAN, APGNN and CPNP to attend a Meet the Professor Breakfast. Meet the Professor Breakfasts: $40 each Indicate top three choices for each day below. Friday, October 26, Hepatitis b y c (in Spanish) (No Charge) 2. Promotion and Career Tracks 3. Advocacy 4. Difficult ethical cases in practice 5. Difficult foreign bodies (spinners, pods, batteries, magnets) 6. The nuts and bolts of pancreatic enzymes and EPI 7. Refractory celiac disease 8. Women in Medicine: Leadership and Diversity and Implicit Bias (No Charge) Saturday, October 27, A problem that is difficult to swallow (in Spanish) (No Charge) 2. Feeding disorders: Evaluation and treatment 3. Nutrition and cholestatic liver disease 4. ERCP for congenital pancreatic abnormalities 5. Refractory constipation 6. Nausea 7. When biologics fail in IBD 8. Stricturing disease in IBD (surgical, medical, endoscopic rx) 9. NAFLD Additional Events Friday and Saturday, October 16-17, There is no additional fee for these sessions. These events are designed for Physicians only. Indicate All Choices Sessions Selected Colonoscopy Skills Workshop 101 (Friday 10:30 am-noon) Colonoscopy Skills Workshop 101 (Saturday 10:30 am-noon) Repeat of Friday session Colonoscopy Skills Workshop 102 (Saturday 3:45 PM 5:15 PM) Please note: in order to register for this session you must have attended the Colonoscopy Skills Workshop 101 at either the 2017 or 2018 NASPGHAN conference. Hands On Motility (Saturday 10:30 am-noon)

4 NASPGHAN Teaching and Tomorrow Program This program covers the PG Course and Annual Meeting attendance. Eligibility: Eligibility: Pediatric Residents with an interest in pediatric gastroenterology, hepatology and nutrition. It is expected that those participating in the program will be the equivalent of a PL-2 resident at the time of the meeting or PL-3 residents considering applying for fellowship to begin in July The Teaching and Tomorrow Program is not designed for residents currently in the process of interviewing for fellowship. Support: Registration includes the Postgraduate Course, Annual Meeting and all the Teaching and Tomorrow events. This includes orientation breakfast on Thursday, a luncheon program on Thursday, a reception on Friday and the closing breakfast on Saturday morning. Participants or sponsoring institutions will be responsible for all travel and hotel costs associated with the meeting. Check here to indicate your selection Teaching and Tomorrow Program $ Social Event, Saturday, October 27, 2018: Indicate All Choices Fee Saturday Social Event No charge Indicate if you are attending Yes Extra Ticket(s) for Saturday $75 Social Event (Adult) Extra Ticket(s) for Saturday $25 Social Even (Child) No NASPGHAN Foundation 5K Registration, 7:00 AM, Saturday, October 27, Please complete the liability wavier along with your registration. Check here to indicate your selection 5K $25.00 Donation, I prefer not to run TOTAL OF ALL ABOVE TRANSACTIONS: Payment Information: MasterCard Visa Discover American Express Credit Card #: Verification Code #: Expiration: Make checks (drawn on a US bank in US funds) payable to NASPGHAN (Mail or Fax completed form to: NASPGHAN / 714 N. Bethlehem Pike, Suite 300 / Ambler, PA Fax: Contact NASPGHAN National Office if further information is needed Phone: / Fax: / naspghan@naspghan.org / NASPGHAN Federal Tax ID: What s Included: Single Topic Symposium Registration fees include continental breakfast, lunch and coffee breaks.

5 NASPGHAN Postgraduate Course Registration fees include Postgraduate course syllabus, continental breakfast, and coffee breaks Annual Meetings of NASPGHAN, APNNN, CPNP Registration fees for the Annual Meeting include the wine and cheese reception on Thursday evening, continental breakfast on Friday and Saturday morning, lunch on Friday and Saturday, coffee breaks, social event on Saturday evening. Cancellation and Refunds: Written cancellations and refund requests must be received on or before October 8, Requests will not be honored after this date. A registration receipt must accompany requests. A refund of the registration fee, minus a $50 administrative fee per each registered item, will be issued after the meeting. Please indicate you understand this policy with a signature: Mail refund requests to: NASPGHAN Annual Meeting Registration / 714 N. Bethlehem Pike, Suite 300 / Ambler PA 19002

6 NASPGHAN 5K Liability Waiver Form Race Date: Saturday, October 27, AM Registration 7 AM Race Starts Hollywood, Florida Last Name: First Name: Address: City: State ZIP Phone: Fax: Emergency Contact: Phone: ( ) - Liability Waiver: Upon acceptance of my entry, I, for myself my heirs and assigns, hereby release the City of Las Vegas, Nevada, Las Vegas Running Tours; NASPGHAN and the NASPGHAN Foundation, all sponsors, and other entities involved with the production of this event from any and all liability arising from illness, injury or death I may suffer as a result of my participation in this event. I attest that I am physically fit and have trained for this event and am aware that my participation could, in some circumstances, result in injury. Should officials determine that completion of this event would be injurious to my health, I consent to be removed and treated by the medical personnel in attendance or their direction. I give permission for free use of my name and picture in any broadcast, telecast or written account of this event. Race will be held rain or shine. NO REFUNDS. Signature: Date NASPGHAN 714 N Bethlehem Pike, Suite 300 Ambler, PA Fax: / Phone: naspghan@naspghan.org NASPGHAN Foundation Federal Tax ID: