2021 “Get Off Your AAS!” Sign Up Form Please select a donation amount*Residents can sign up with a minimum donation of $50 ($250 for a team of five). Attending physicians can sign up with a minimum donation of $100 per person ($500 for a team of five). Teams of five must be signed up all together by one person.$500$250$100$50OtherOther Amount* Please select a participant to sponsorPlease select a nameJessica ZagoryNicole WilsonTracy WangAshley WaltherGlenn WakamOliver VarbanAllison SpeerCarmen SolorzanoSri SharmaLibby SchroederShelley ScerboTammy SaundersKelly SandersRob RussellTaylor RiallTeddy PuzioMarina PetsalisCarrie PetersonAllan PeetzNikhil PandaNick OsborneAndrea ObiLilah Morris-WisemanColin MartinAlisha LussiezStefan LeichtleKevin LallyGifty KwaykeGifty KwakyeHeather KregelMio KitanoColleen KiernanGregory KennedyLillian KaoKayla IsbellAndrew IbrahimTasha HughesBob HollisJulie HolihanGabriela HobbsMarion HenryPeter HenkeAlexander HawkinsGabrielle HattonTimothy HarrisNikki HarrisVikas GuptaStephanie GrecoAmir GhaferiShawn GawleDillon GasperJeffrey FarmaRyan EtonJuliet EmamaulleeAnu ElegbedeAnnie EhlersCasey DuncanLesly DossettShah DodwadLuke CrawfordMeg CoughlinCallisia ClarkeDan ChuShannon CastleKeith BurczakJason BrillBrooke BredbeckSidra BonnerMeredith BarrettMary AustinErik AskenasyMary ArbuthnotMaia AndersonYewande AlimiSasha AdamsNaji AbumradOr add new participants / team (up to 5 people at once)Add New ParticipantsPlease add a new participant using the Add Participant button below. If you are adding a team, just keep adding new participants until you reach the limit of 5 people (or fewer). Participant Name Institution Actions Edit Delete There are no Participants. Add Participant Maximum number of participants reached. Payment InformationCardholder Name* First Last Your Institution/OrganizationEmail for receipt* Credit Card Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Security Code Cardholder Name Your Membership Type*AAS MemberNon MemberYour Membership Type*AAS MemberSUS MemberAAS and SUS MemberNon-member Share this:TwitterFacebookLinkedInPrint