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Regional Event Pre-Planning Form

Filling out the Regional Event Pre-Planning Form will allow your Regional Vice-Chair and the WDS National Office to understand your goals and needs to help make your event a success.

Your WDS Regional Vice-Chair will be an invaluable resource during your planning. Each Vice-Chair is an experienced physician and leader within the WDS. They will be able to provide you with ideas, support, advice, tips, put you in contact with local industry reps, and much more.

Questions? Contact WDS at 1-877-WDS-ROSE or

* Required fields

1. Information

Date: May 24, 2020
Name: *
Address: *
City: *
State: *
Zip: *
Phone: *
Email: *
Name of Affiliation/Institution:
Please check your membership type: * Active   Associate   Corporate   Resident
1st Year Post Residency   International   Honorary/Life Member
Have you hosted a WDS Regional Event before: * Yes    No
Name(s) of WDS Members Assisting
(if applicable):

2. Events Information

Event Name: *
Event Location: *
Date of Event: *
Event Time: *
Event Type: * Educational   Networking   Program   Service
Anticipated Audience: *
Anticipated Number of Attendees: *
Goal of Event: *
Do you need a WDS Membership Listing: *
(If YES, please complete the information below.)
Yes    No
Geographical Region:
(be as specific as possible - city, state(s), institutions)
Do you need WDS to create an Evite for you: * Yes    No
Registration Fee / Fee to Attend:
(if applicable)
RSVP Method:
Contact Info for Questions:
Sponsor (if applicable):
Additional Information and Incentives:
(industry product, giveaways, refreshments,
dress code, parking, etc.)

3. Advertising

I would like the WDS office to complete the
following to help with advertising for my event
(check all that apply):
WDS Eblast to members. How many times/how often?
Post on WDS Website under 'Regional Events'
Share on WDS Social Media. How many times/how often?
Comments / Additional Requests:

4. Event Materials

The WDS office will supply you with the following materials for your event:
Membership Applications, Brochures (member, awards, sponsorship, and International Journal), and WDS Pens

Ship to the address provided above.

Please, complete shipping address below if different from above.

Shipping Address:
Shipping City:
Shipping State:
Shipping Zip:

If there are additional items you would like to receive please indicate you request in the Special Request for Materials section below.

Special Request for Materials:
* WDS will do their best to accommodate all material/supply requests, but cannot guarantee it.