* indicates required fields
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* First Name:
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* Last Name:
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* Primary Degree:
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* Degree(s) as it should appear on your certificate:
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| *Are you a medical resident or student?
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* Specialty:
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Secondary Specialty:
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* Address:
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* City:
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* State:
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* Zip Code:
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* Country:
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* Phone Number:
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Fax:
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Emergency Contact Name:
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Emergency Contact Phone Number:
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* Email Address:
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Special Instructions:
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Additional Demographic Information for Federal Grant:
The following questions include information about your age, race, ethnicity, and employment. These questions are necessary to comply with the terms of a public health education grant, which requires us to report that information for all attendees. The grant is helping us to keep down the price of this event. We appreciate your assistance in providing the necessary information. The data will be reported in aggregate numbers to representatives of the New England Alliance for Public Health Workforce Development, which is supported through grants from the U.S. Health Resources and Service Administration. All information collected on individual participants is kept strictly confidential.
Gender:
Age:
Race:
Ethnicity:
Occupational Discipline (please select the option that BEST applies to your position):
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* Do you want to be included on the BUSM CME e-mail list?
Yes
No
* Do you want to be included on the conference participant list?
Yes
No |
TUITION: $75 per person ($50 for medical residents and students)
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Substitution/Cancellation Policy
Substitutions may be made at any time without additional charge. Cancellations/ substitutions must be made in writing at least two weeks prior to the start of the conference. This conference is subject to change and/or canellation.
Special Services/Dietary Needs
To request reasonable accommodations for disabilities, please notify the CME office, in writing, at least two weeks prior to the start of the conference. The CME office will work to accommodate dietary requests (including, but not limited to: kosher, vegetarian, low- cholesterol, and low-sodium meals) received, in writing, at least two weeks prior to the start of the conference. |
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