Faculty and Resident Registration

Name

First Last

Program

Residency program or affiliated hospital

Date of arrival

Please list the date you will arrive at Big Cedar. The course begins Thursday, November 6th at 7am, Hotel accommodations will be provided for attendees arriving Wednesday, November 5th. *Once arrival/departure dates are confirmed, the attendee is responsible for any billed charges incurred from room accommodations that are unused due to delayed check-ins.

Date of Departure

Please list the date you will be departing Big Cedar. The course concludes on Saturday, November 8th at 3:30pm, Hotel and dinner accommodations will be provided for attendees staying until Sunday, November 9th.

Will your stay be extended through Sunday and you need dinner accommodations on Saturday night?

Yes

Travel Method

Date of Birth

Name as it appears on your ID

Preferred Airport

Frequent Flyer Number

Shirt Size

Scrub Size

Phone Number

Food Allergies

Thursday Activity

Due to AdvaMed guidelines, activities will be provided by Springfield Neurological Institute.

Name of Significant Other

If accompanying you, we will be happy to help with accommodations, however, due to AdvaMed guidelines, we are only able to cover our physician attendee accommodations. Dinners will be provided by Springfield Neurological Institute.

First Last

Name of Children

If accompanying you, we will be happy to help with accommodations, however, due to AdvaMed guidelines, children may not be included in dinners or activities.

Firstname

Lastname

Consent*

I have read and agree to the policies.

Phone

This field is for validation purposes and should be left unchanged.

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Physician

Nursing

CO-VENDORS

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Important Links

Physician

Nursing

CO-VENDORS

Contact Info