Registration Form

Registration
NAME (Last)
(First)
EMPLOYER
(Middle Initial)
NAME ON BADGE
ADDRESS
CITY, STATE, ZIP CODE
PHONE
E-MAIL ADDRESS
*SPOUSE/GUEST NAME
NAME ON SPOUSE/GUEST BADGE
EMERGENCY CONTACT NAME
EMERGENCY CONTACT PHONE
FEES AND PAYMENT INFORMATION
ANNUAL MEETING REGISTRATION
Amount
After 8/1/2015
AIPG Member Full Registration
$395.00
$495.00
$
Non-Member Full Registration
$445.00
$545.00
$
Daily Registration
$220.00
$220.00
$
Spouse/Guest Full Registration (Admission to Welcome
Reception, Breakfast, Lunch, Breaks and Exhibits)
$195.00
$195.00
$
Student Full Registration
$45.00
$45.00
$
I Would Like to Support Student Registration
$45.00
$45.00
$
FIELD TRIPS (Must be Registered for the Conference)
Amount
After 8/1/2015
Pre-Conference Field Trip — Fairbanks, Alaska - Fort Knox
Gold Mine and Permafrost Tunnel Tours (begin and end in
Fairbanks) (Thurs., 9/17, 8:00 am – 6:00 pm)
$149.00
$199.00
$
2-day Field Trip — Denali National Park and Usibelli Coal Mine
Tour (Sat., 9/19, 6:00 am – Sun., 9/20 6:30 pm)
$575 Single Room
$525 Dbl Room
$675 Single Room
$625 Dbl Room
$
2-Day Field Trip — Glacial Geology of the Upper Kenai
Peninsula (Sat., 9/19, 8:00 am – Sun., 9/20 6:00 pm)
Wishbone Hill, Palmer, Alaska
(Sat., 9/19, 8:00 am – 6:00 pm)
Matanuska Glacier
(Sun., 9/20, 8:00 am – 5:00 pm)
$475 Single Room
$425 Dbl Room
$575 Single Room
$525 Dbl Room
$
$139.00
$189.00
$
$169.00
$219.00
$
$59.00
$79.00
$
$139.00
$189.00
$
$99.00
$149.00
$
$139.00
$189.00
$
□Sat □Sun □Mon □Tues
Alaska Volcano Observatory
(Sun., 9/20, 2:00 pm – 5:00 pm)
Transect of the Mesozoic Subduction Complex, Southcentral
Alaska (Mon., 9/21, 7:30 am – 5:30 pm)
Backstage Tour of the New Alaska Geological Materials Center
and a Tour of the Alaska Volcano Observatory
(Mon., 9/21, 10:30 am - 5:00 pm)
Turnagain Arm Geology Tour
(Tues., 9/22, 8:00 am - 5:00 pm)
Amount
Amount
FIELD TRIPS (Must be Registered for the Conference)
Amount
After 8/1/2015
1964 Great Alaska Earthquake: Geologic Causes and Effects
(Tues., 9/22, 8:00 am - 12:00 noon)
Amount
$59.00
$79.00
$
Backstage Tour of the New Alaska Geological Materials Center
(Tues., 9/22, 10:00 am – 11:30 am)
$59.00
$79.00
$
SOCIAL EVENTS/DONATION (Must be Registered for Conference)
Welcome Reception (Sun., 9/20, 6:30 pm – 8:00 pm)
Amount
(please circle if attending)
Included with Registration
Awards, Dinner and Entertainment (Mon., 9/21, 6:30 pm – 8:30 pm)
$65.00
Make a Donation to the Foundation of the AIPG
$
TOTAL AMOUNT DUE
$
$
$
AIPG Meetings (see Program for Dates and Times) – Please Indicate if Attending
AIPG National Executive Committee Meeting (9/18)
AIPG 2015 Advisory Board Meeting (9/18)
Attending
yes / no
yes / no
AIPG 2015-2016 Joint Executive/Business Mtg. (9/18)
Attending
yes / no
Full AIPG Registration Includes: Welcome Reception, Technical Sessions, Student Poster Sessions, Exhibits, Registration Materials,
Continental Breakfast, Lunch, and Breaks on Monday, and Tuesday.
I understand that by registering for the 2015 AIPG Conference & Exhibition, I release and agree to indemnify The American Institute of
Professional Geologists (AIPG), their agents, officers, volunteers and employees from all liability for any loss, damage or injury sustained by me while involved in any way with the Conference and Exhibition except that AIPG is not released from such liability to the
extent the same is caused by its actual negligence or willful misconduct. I have read and understand this waiver and release.
I also understand that submission of this registration form gives AIPG the authority to utilize any photograph taken of me at the conference for conference related publicity (e.g., web site, TPG, videos, etc.).
Hotel Information: Hilton Anchorage, 500 West Third Avenue, Anchorage, Alaska 99501-9953, (907) 272-7411. For reservations call
1-800-HILTONS and be sure to use the group code AIPG15 to receive the reduced conference rate of $137 a night, which will be honored
until 9/19/15.
Photo on page one: Flattop, by Roy Neese.
TOTAL AMOUNT DUE $__________
METHOD OF PAYMENT
PLEASE CHECK METHOD OF PAYMENT
Check No.__________ Enclosed (drawn in U.S. Dollars on a bank located in the US or Canada)
International Postal Money Order (in U.S. Dollars)
VISA
Master Card
American Express (Credit cards are processed in US dollar amounts only)
Card No.____________________________________________Expiration Date___________ CVV _________
Print name of cardholder:___________________________________________________________________
REQUIRED: Credit Card Billing Address (street, city, state, and zip):
_________________________________________________________________________________________
_________________________________________________________________________________________
Authorized Signature_______________________________________________________________________
Mail to:
American Institute of Professional Geologists
12000 N. Washington Street, Suite 285, Thornton, CO 80241
or fax to (303) 253-9220 or register on-line at www.aipg.org, phone (303) 412-6205
Refund Policy: A 90% refund of total fees paid (10% withheld to cover administrative costs) will be given upon receipt of a written request until 7/31/2015. Cancellations made by written notification received between 8/1/15 and 9/10/15 will be assessed a charge of 20% (to cover administrative costs) of the total fee paid. NO
refunds will be given for cancellations received after 9/10/15 or for no-shows after the meeting. Substitutions welcome. Based on the decision of AIPG, field trips are
subject to cancellation due to lack of participation. Notification and a full refund for field trips will be given in case of required cancellations.