October 30, 2008

School of Medicine-Wichita
Wichita, KS

 November 6, 2008

The University of Kansas Medical Center
Kansas City, KS

 I would like to register for both conferences.

Name:

Suffix (e.g: M.D, Jr.)

Organization:

Address:

City/State/Zip:

Phone:

Email:

 Resident Physician
 Name of School Attending

 Program

 Program Level    1 2 3 4 5

 Medical Student
 Year    1 2 3 4 5

 Allied Health Student

 Nursing Student

 Pharmacy Student

 Nurse Practitioner

 Physician Assistant

 Nurse

 Other

 My spouse will attend.
 Spouse name