CardiovasCular TopiCs at Johns hopkins - Hopkins CME Blog
CardiovasCular TopiCs at Johns hopkins - Hopkins CME Blog
CardiovasCular TopiCs at Johns hopkins - Hopkins CME Blog
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EGisTraTion ForM Course Number: 80022781<br />
The Nicholas Fortuin Cardiovascular Topics <strong>at</strong> <strong>Johns</strong> <strong>Hopkins</strong><br />
February 17 - 19, 2011<br />
To Register: Online: www.<strong>Hopkins</strong><strong>CME</strong>.edu By fax: (866) 510-7088<br />
By phone (credit card only): (410) 502-9636<br />
Or mail this form to the <strong>Johns</strong> <strong>Hopkins</strong> University, Office of Continuing Medical<br />
Educ<strong>at</strong>ion, P.O. Box 64128, Baltimore, Maryland 21264-4128. Include check payable<br />
to HOPKINS/80022781 or include credit card inform<strong>at</strong>ion below.<br />
PAYMENT MUST ACCOMPANY FORM TO CONFIRM YOUR REGISTRATION.<br />
Please type or print clearly:<br />
last name first name middle initial<br />
primary degree (for name badge) primary specialty<br />
preferred mailing address<br />
city st<strong>at</strong>e ZIP + 4 code country<br />
daytime telephone fax number<br />
e-mail / / / / / / / / / / / / / / / / / / / / / / / / / / /<br />
You will receive confirm<strong>at</strong>ion notice by e-mail if you provide your e-mail address.<br />
M Check here if you wish to receive e-mail and/or fax notices about upcoming <strong>CME</strong> activities.<br />
Wh<strong>at</strong> do you hope to learn by <strong>at</strong>tending this activity? _____________________<br />
Please notify us if you have any special needs. __________________________<br />
REGISTRATION FEES: EARLY-BIRD FEES<br />
POSTMARKED POSTMARKED<br />
BEFORE 12/31/10 AFTER 1/1/11<br />
M Physicians ..................................................................... $395 .....................$475<br />
M Residents*/Fellows*/Allied Health Professionals ....... $210 .................... $250<br />
*with verific<strong>at</strong>ion of st<strong>at</strong>us<br />
M †ACLS Course (Optional) ................................................ $130......................$140<br />
For registr<strong>at</strong>ions received after 5:00 p.m. EST on February 11, 2011, include a $50 l<strong>at</strong>e fee. On-site<br />
registr<strong>at</strong>ions are payable only by credit card.<br />
ACLS COURSE or MEET THE PROFESSOR SESSIONS:<br />
(Please select EITHER the ACLS course OR the Meet the Professor Sessions AND Clinical Problem<br />
Solving Symposium below.)<br />
M †ACLS Course: (Thursday and Friday with testing on Friday – required for certific<strong>at</strong>ion)<br />
OR<br />
M Meet The Professor Sessions/Clinical Problem-Solving Symposium (Thursday):<br />
Please indic<strong>at</strong>e your choice in order of preference (1 - 5). You will <strong>at</strong>tend two sessions. Every <strong>at</strong>tempt<br />
will be made to assign you your first and second choices.<br />
A. Prevention D. Electrophysiology<br />
B. Peripheral Arterial Disease E. Women’s Cardiovascular Health<br />
C. Echocardiography<br />
AND<br />
Group Symposium: (Friday – for those <strong>at</strong>tending the Thursday Meet the Professor Sessions)<br />
Payment Type:<br />
TOTAL AMOUNT ENCLOSED: $ __________<br />
JHU Faculty/Staff Only: Complete registr<strong>at</strong>ion form and return with appropri<strong>at</strong>e form below to O<strong>CME</strong>,<br />
Turner 20.<br />
M Internal Order Number: The ION D<strong>at</strong>a Request Form, can be found online <strong>at</strong><br />
http://www.<strong>hopkins</strong>cme.edu/pdfs/IonRequest.pdf.<br />
M Tuition Remission: To apply for TR, go to http://benefits.jhu.edu/EduBenefits/tuitionRemission.cfm.<br />
This is a non-credit professional development activity.<br />
M Check (See instructions on top of form.)<br />
M Credit Card: M VISA M MASTERCARD M DISCOVER M AMEX<br />
Card # - - - Exp. D<strong>at</strong>e ________<br />
Name on Card Sign<strong>at</strong>ure & D<strong>at</strong>e