Contact Information

Name  

Gender   Family - specify in comments Male Female

Address  

City  

State  

Zip  

Phone  

Email  

Program or School Information

Program   Medicine Resident Practitioner/Fellow Dental Nursing OT PA Pharmacy Pre-med Podiatry Post-Bac/Grad Student PT Other (please specify in comments)

School   Completed School Albert Einstein Brown Columbia University Cornell University Drexel University Georgetown Jefferson University Johns Hopkins University Mount Sinai NYMC NYCOM NYU PCOM Pennsylvania State University SUNY Buffalo SUNY Downstate SUNY Upstate Temple University UMDNJ-New Jersey Medical School UMDNJ-Robert Wood Johnson Medical School UMDNJ-SOM (Osteopathic) University of Maryland Uniformed Services University University of Pennsylvania University of Virginia Virginia Commonwealth University School of Medicine Other (please specify in comments)

Lodging and Cost

Accommodations   $110 Single Sharing Room with 4-5 people $240 Married couple sharing 1BR and living room with another couple $320 Married Couple, 1BR unshared

Please check if applying for financial assistance, and specify amount in comments below

I am interested in babysitting for one of the four sessions to help the Winter Conference reduce expenses

I am interested in giving a ride to others.

Roommate Preferences (If any, please separate with commas):

Additional Comments (If any, scholarship amount requested, etc.):

I understand I must send a nonrefundable $30 deposit to complete my registration

Yes, I understand I do not have a room reserved until I send my deposit