GERIATRIC MEDICINE LEADERSHIP TRAINING - GeroNet - UCLA

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Program DatesFriday and SaturdayMarch 24 & 25, 2006LocationMarina del Rey Marriott Hotel4100 Admiralty WayMarina del Rey, California 90292(310) 301-3000GENERAL INFORMATIONAccommodationsRooms are available at the Marina del Rey Marriott Hotel at the specialUCLA business rate of $189 per night for either single or double occupancyplus tax. Please call (800) 228-9290 to make reservations; identify yourself asa participant in the Geriatric Management Leadership Training and ask for theUCLA business rate. All reservations are subject to availability.ParkingThere is a special daily conference rate of $10 for self-parking and $20 forvalet parking.For additional information, contact Ms. Denise Gutierrez at the CaliforniaGeriatric Education Center, David Geffen School of Medicine at UCLA, 10945Le Conte Ave., Suite 2339, Box 951687, Los Angeles, CA 90095-1687Phone: (310) 312-0531 and Fax: (310) 312-0546E-mail: dgutierrez@mednet.ucla.eduPlease visit our website for additional copies of this brochure and formore information about upcoming programs.www.geronet.ucla.edu
ENROLLMENT FORMGeriatric Medicine Leadership Training, March 24 & 25, 2006Please printName (First/MI/Last) ___________________________________ Degree(s) _________Faculty Position/Title ____________________________________________________Organization/Affi liation ___________________________________________________Mailing Address ________________________________________________________□ Home □ Offi ceCity/State/Zip _________________________________________________________Phone (________)_______________________ E-mail _________________________Daytime phone number with area codeI will attend the networking dinner on Friday evening (additional fee of $25).I will bring a guest to the dinner (additional fee of $25).(Yes / No)(Yes / No)Fees: $595 □ if registered before February 24, 2006$695 □ after February 24, 2006(Includes continental breakfast, lunch, program materials, and education credits)$25 □ Dinner $25 □ Guest DinnerTotal Amount $ _________________Method of Payment□ Check enclosed payable to: REGENTS OF THE UNIVERSITY OF CALIFORNIA□ MasterCard □ VISA □ Discover Card □ American ExpressCard #___________-___________-___________-___________ Exp Date ____/________________________________________________________________________Authorized SignatureName Printed on CardThe vendor name on your credit card statement will be “200 Medical Plaza.”Mail to:FAX to:California Geriatric Education CenterDavid Geffen School of Medicine at UCLA10945 Le Conte Avenue, Suite 2339, BOX 951687Los Angeles, CA 90095-1687Attn: Denise Gutierrez(310) 312-0546 (Credit Card Only)For additional information, please call (310) 312-0531 or go to www.geronet.ucla.edu.
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GERIATRIC MEDICINE LEADERSHIP TRAINING - GeroNet - UCLA

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