Last Name:

First Name:

Middle Name:

Degree:

License # (Required for credit):

Address:

City:

State:

Zip Code:

Day Phone:

E-Mail:

Physician ($175) (Specialty)
Other ($120) (Specify)
KU Resident Physician (with preregistration, no charge)
KU Medical Student (with preregistration, no charge)

Using the program printed in the brochure, please select a first and second choice for each set of concurrent sessions. Assignments will be made as registrations are received. Every possible effort will be made to honor first-choice requests.

11:05 a.m. - 12:05 p.m. (4,5,6)

3:25 p.m. - 4:25 p.m. (10,11,12*)

10:40 a.m. - 11:40 a.m. (16,17,18)

*Session #12 to adjourn at 4:55 p.m.

Do you plan on attending the Friday Vol-Docs breakfast?
Yes
No

Yes
No

Paper
CD
Flash Drive
Web Site

   Will pay via phone, 316-293-2636 or 800-720-0905