Amount:

First Name:

Middle Initial:

Middle Name:

Last Name:

E-Mail:

Phone (###-###-####):

Institution Name

Street:

City:

State:
Select a state AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington, D.C.West VirginiaWisconsinWyoming

Zip:

Name of Preceptor Attending Conference

Preceptor's Email Address:

Please enter EXACT title of submission (the title will be printed in the conference program booklet EXACTLY as submitted here)

Please enter the name(s) of the author(s) separated by commas. Omit degree designations.

Please describe your Educational Goal. Your educational goal should be stated in general terms and describe the overall goal for the program, allowing participants to be quickly informed about the nature of the program.

Please provide ONE to TWO Learning Objective Pertaining to Your Presentation Topic. Learning objectives should be clear and measurable. They should express clearly what the learner should be able to do with the subject content. Use an action verb, but avoid ambiguous or imprecise verbs. When phrased correctly and used appropriately, learning objectives help the presenter and the learner gain the most out of a well-organized educational program.

Check ONE of the following practice interest categories for this submission:

Select One
Primary Care/Ambulatory Care
Clinical Services Management
Internal medicine
Infectious Disease
Pediatrics/Neonatology
Hematology/Oncology
Critical Care
Cardiology
Community Practice
Pharmacy Practice
Transplant
Psych

Current Postgraduate Year

Select One
PGY1
PGY2

Residents/Fellows Accompanied by a Preceptor

Select One
$260.00 If registered and fee paid by Feburary 26 2010
$315.00 LATE REGISTRATION FEE: If registered and fee paid between Feburary 27 and March 4 2010

Residents/Fellows Unaccompanied by a Preceptor

Select One
$315.00 If registered and fee paid by Feburary 26 2010
$370.00 LATE REGISTRATION FEE If registered between Feburary 27 and March 4 2010

Name of Roommate(s)

Name of Roommate(s) Institution

Special Instructions/Requests - i.e. - beds/room, sofa sleeper, smoking preference, private room, etc. (Private room requests will be accepted space permitting and residents WILL BE CHARGED for 50% room and tax fees.)

Planned Arrival to facilitate the room reservation process: (Presenters are encouraged to be at the conference by 5 PM on Wednesday, May 4th and expected to be there no later than 8 AM on Thursday, May 5th

Select One
Wednesday May 4th
Thursday May 5th

Planned Departure - to facilitate the room reservation process.

Select One
Thursday May 5th
Friday May 6th
Saturday May 7th

Payment Options
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