Registration Form Clinical Vaccinology Course Ma...
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National Foundation for Infectious Diseases (NFID): Clinical Vaccinology Course

Published on: Mar 3, 2016

Transcripts - National Foundation for Infectious Diseases (NFID): Clinical Vaccinology Course

  • 1. Registration Form Clinical Vaccinology Course March 8-10, 2013 Hyatt Regency chicago, 151 east wacker drive, chicago, il 60601(Please print clearly or type; photocopy for additional registrants)Last name First name Middle initial Nickname (for badge)Professional title EmployerDegree(s) (circle all that apply)BA BS DO MA MD MPH MS NP PharmD PhD RN RPh Other (please specify):_________________________________________________________________________Primary practice area (circle one) Primary profession (for CE credit designation) (circle one)Academia Pediatric ID Physician Nurse/Nurse Practitioner Physician Assistant PharmacistAdolescent Medicine Preventive Health/Public Other (please specify): _____________________________________________________________________________ HealthFamily Medicine What percentage of the work day are you involved in direct patient care? (circle one) Research (non-clinical)Geriatrics 0% 1-25% 26-50% 51-75% 76-100% Travel MedicineImmunology Other (Please specify): How did you hear about this course? (circle all that apply)Industry _______________________ Colleague E-mail Invitation Meeting/Tradeshow NFID Website Previously Attended Print MailingInternal Medicine _______________________ Other (please specify): _____________________________________________________________________________Internal Medicine ID _______________________Pediatrics What was the major determining factor in registering for this course? (circle one) Content/Topics Continuing Education Credits Cost Invited Speakers Location Other (please specify): _____________________________________________________________________________Mailing AddressCity State Postal code CountryTelephone E-mail address❑ Do not include my contact information on the Attendee List.Special Needs ❑ Check or money order drawn on US funds (made payable toList any special meeting needs or requirements you may have in NFID) enclosed in the amount of $ _____________________the space below, or contact Sharon Cooper-Kerr at 301-656-0003 x14, ❑ Please bill my credit card in the amount of $_____________________or Check type of card ❑ Visa ❑ MasterCard ❑ American Express_________________________________________________________________ Name as printed on cardPayment (circle the amount enclosed)Early REGISTRATION Card number Security Code Expiration dateThe Early Registration deadline is January 21, 2013$590 Registration (includes complimentary one-year NFID Signature Supporting Membership)$495 NFID Supporting Member Billing address (if different from registrant’s mailing address)$275 Doctor-In-Training*†$275 Nurse† NFID Supporting Membership Registration includes a complimentary one-year NFID Supporting Membership.$225 Daily (select one) ❑ FRI. ❑ SAT. ❑ SUN. Additional Supporting Member benefits include subscriptions to NFIDfull REGISTRATION publications and newsletters. For additional details, visit$690 Registration (includes complimentary one-year NFID supportingmember. Supporting Membership) ❑ No, I do not wish to accept the complimentary one-year supporting membership.$595 NFID Supporting Member$375 Doctor-In-Training*† Cancellation Policy Refunds, less a $75 administrative fee, will$375 Nurse† be granted only if written notification is received at NFID prior to 5:00 pm ET on$325 Daily (select one) ❑ FRI. ❑ SAT. ❑ SUN. January 21, 2013. There will be no refunds for cancellations made after this date. Substitutions will be allowed; however, you must notify NFID as soon as possible.* Includes medical students, doctoral students, residents, fellows, and physician assistants. The program organizers reserve the right to cancel this course at any time. In the† Verification of status must be provided in the form of a letter from your program director or for event of a cancellation of the course, the full registration fee will be returned to thenurses, a copy of your valid nursing license. registrant.

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