HeAltH inFOrMAtiCS - UC Davis Extension

ENROLLMENT APPLICATION5TH ANNUAL HEALTH INFORMATICS(Please Print) March 18, 2011________________________________________________________________________________________________First Name MI Last NameMD DO PharmD RPh PA NP RN Psychologist Other______________________________________________________________________________________________________________________Institution/Employer (as you would like it to appear on your badge)Profession / Occupation________________________________________________________________________________________________Address (where you would like your receipt mailed)________________________________________________________________________________________________City State Zip Code(________________________________________________________________________________________________) ( )Day PhoneFax NumberEMAIL ADDRESS REQUIRED FOR IDENTIFICATION PURPOSES________________________________________________________________________________________________Physician information required for CME credit and name badge. Please indicate primary medical specialty:FP GP IM Other (specify)___________________________________________________________________Social Security Number (last 4 digits required for transcript purposes)Have you attended thisconference in the past?X X X X XYes NoPlease copy the mail code from the address side of the brochure(above your name, e.g. PPMED, MMSMED, CRDMED)_______________________________________________________If you did not receive a brochure in the mail, how did you hear about this conference?(Example: PT&MG, UCD website, web search, magazine, friend)?_ ______________________________________________REGISTRATION FEES (Receipt/Confirmation will be mailed within two weeks)Early Discount After Feb 18 On SiteCommunity Participants $185 $ 210 $235UC DAVIS AFFILIATE FEES (Please specify) Faculty Volunteer Faculty Alumni Staff PCNEarly Discount After Feb 18 On SiteUC Davis Participants $150 $ 170 $1907 Digit Acct. # Authorized Signature and Phone # DepartmentElectronic SyllabusIn our efforts to “go green,” our syllabus will be available on USB Flash Drive this year. We will have outlets available foryour laptops.After conference Networking ReceptionI will attend the receptionSend Sacramento lodging information.If you need disability accommodations at the meeting, please let us know by February 28, 2011, and our representativewill contact you.Please note special dietary/food allergy requirements ____________________________________________________Please check your payment method. Enrollment forms received without check, credit cardnumber or purchase order number will not be processed until payment is received.Check enclosed payable to: UC RegentsAMEX Discover MasterCard VISA_________________________________________________________________________________________________Account NumberExpiration Date_________________________________________________________________________________________________Authorized Signature (name on card)Security CodePlease use ONE of these methods to register: (Do not mail if previously faxed or telephoned)Mail application and payment: Office of Continuing Medical Education, c/o UC Davis Cashier’s OfficeP.O. Box 989062, West Sacramento, CA 95798-9062Telephone: (916) 734-5390 Fax application (916) 734-0742Register online: http://cme.ucdavis.edu/conferencesFor office use onlyMEDIF116193