REGISTRATION FORM
The Pathology of Tumors in Children
August 2009
To register, print out this application form and mail with check or fax with credit card information.
Practicing physicians,
Physicians in training, nurses, investigators,
The fee includes breakfast and refreshment breaks each day. Various printed materials, including a conference syllabus will be provided. A 24 microscopic set of pediatric tumor cases with clinical histories will be given to all participants and may be retained for their files.
Early registration is recommended as attendance is limited. A $100 processing fee will be charged for cancellation up to 21 days before the beginning of the conference; no refunds after that time unless your place can be filled.
Make checks payable to
Institute for Pediatric Medical Education
Amount Enclosed_________
Name______________________________________
Preferred 1st name on nametag__________________
Address____________________________________
_____________________________________
City/State/Zip+4_____________________________
Tele__________________Fax__________________
E-Mail (For confirmation of registration and for conference information updates)____________________________
Social Security # (For CME)____________________
Specialty___________________________________
Mail to: Institute for Pediatric Medical Education
6604 Landon Lane
Bethesda, MD 20817-5636