REGISTRATION FORM

The Third National Forum
On Women's Issues in
Gastroenterology and Hepatology

April 4 - 6, 2008
Radisson Plaza - Warwick Hotel
1701 Locust Street
Philadelphia, PA 19103

Click the SUBMIT button below to pay by credit card, OR
print this form and mail it with a check to:

Office of Continuing Medical Education
Drexel University College of Medicine
1427 Vine Street, Ste. 405, MS 1013
Philadelphia, PA 19102

or

Fax to: (215) 762-2589
First Name:
Middle Initial:
Last Name:
Degree:
Specialty:
Institution:
Institution Street Address:
City:      State:    Zip Code: 
Day Phone Number:
Fax Number:
E-Mail Address:

Home Address (Certificates will be mailed to this address)
Street Address
City:      State:    Zip Code: 

Check if you desire a 
Vegetarian Meal
Check if you have a  Physical Need

(Please Advise by 3/21/08)
 
Will you attend Friday's Reception and Dinner? Yes/No:  

Please list below your selected breakout sessions:
Friday, April 4 (5:20-6:20 PM) 1st choice:  
  2nd choice: 
Saturday, April 5 (1:20-2:20 PM) 1st choice:  
  2nd choice: 

Registration Fee:
Postmarked by 2/4/08
   Postmarked after 2/4/08
Physicians
$150
    $175
Allied Health Professionals
$100
    $125
Fellows, Residents, Students
$50  
    $70

Travel grants will be offered to fellows/residents whose posters are
selected for presentation.(For details, call the Office of CME at 215-762-2580)

Cancellation Policy:
A full refund less $20 will be given until 3/21/08.
Refunds will be issued after the program.
No refunds will be granted after 3/21/08.

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