2008 DBP Fellowship Training Annual Meeting
Registration Information
Note: Fields marked with an
*
are requred.
First Name
*
:
Last Name
*
:
Address:
Office Telephone:
Office Fax:
E-mail Address
*
:
Academic Title:
Hospital Title:
Faculty or Fellow
*
:
Faculty
Fellow
Other:
Male or Female
*
:
Male
Female
Nights accommodation at Omni Shoreham Hotel:
(if needed)
Tuesday, April 22
Wednesday, April 23
Thursday, April 24 (If travel requires – Hawaii only)
Room:
Single Room (faculty; or self-pay option for fellows)
Double Room
Fellows
:
With whom would you like to room?
(*NOTE: The grant supports single occupancy for up to 2 faculty from each program, and shared rooms for fellows. Fellows who do not provide the name of a room-mate will be assigned room-mates. If more than 2 faculty will be attending from your program, rooms may be shared without any added cost to the individual or their program for the extra person. Additional single rooms can also be arranged for fellows or faculty at a cost of $201 per night plus tax ($230.14), if available.
Other particular needs
:
Attendance at Meals
:
Wednesday Continental Breakfast (Fellows only)
Wednesday Dinner
Thursday Continental Breakfast
Thursday Lunch
Special Dietary Needs
:
Vegetarian
Kosher
Other:
For Fellows:
Will you be submitting an abstract?
(Fellows only)
Yes, I would like to submit an abstract now.
Yes, I will be submitting an abstract at a later date.
No, I will not be submitting an abstract.