|
Print and
complete the entire form. Make your check or money order payable
to "Baylor College of Medicine-Pediatrics" and mail
with your registration form by February 8, 2008 to:
Diane M. Anderson, PhD, RD
Baylor College of Medicine
Department of Pediatrics, Section of Neonatology
6621 Fannin St., MC WT 6-104
Houston, TX 77030
|
Please indicate a preferred mailing address by checking the appropriate box.
Registration Fee |
◻ Physician—$325
◻ Allied Health Professional—$275 |
Name |
◻ Home address |
Street |
|
City |
State |
Zip code |
Phone |
◻ Business address |
|
Business Name
|
Street |
|
City |
State |
Zip code |
Phone |
Email |
Occupation/Title |
Nature of Practice |
◻ RN |
◻ RD |
◻ MD |
◻ Other (specify)
|
|
Highest Academic Degree |
Check type of work performed |
◻ Clinical |
◻ Teaching |
◻ Research |
◻ Student |
◻ Public Health |
◻ Other (specify)
|
|
Indicate choice of workshops |
|
Monday, March 3, 2008
|
2:00 pm |
|
3:50 pm |
|
|
|
Tuesday, March 4, 2008
|
2:00 pm |
|
3:50 pm |
|
|
|
|