Registration Form
GENETICS AWARENESS PROJECT
Why We Can't Wait: Conference to Eliminate Health Disparities in Genomic Medicine
May 31 - June 1, 2012
* Last Name: * First Name: Middle Initial:
Degree: Degree Other:
Occupation:
* Will you need CME or CEU Credits?  Payment will be collected at the conference. Details to follow.

Last 4 digits of social security number:      (for CME/CEU recording and identification purposes only)
If you are a foreign participant and do not have a Social Security #, please enter 1111.
Preferred Mailing Address:

If using institutional address, please include department (if applicable) and institutional name
Department:
Institution:
* Street:
Street 2:
City: State: Zip Code: (Zip+ 4: xxxxx-xxxx)
For International Addresses:
Region/Province:
Postal Code:
* Country:
* Phone: (Do not include hyphens) Fax:
(Do not include hyphens)
* Email:
* Confirm Email:
Registration Fees

Registration fees are listed below.
I am registering for:
* Early Registration
Before April 27, 2012
 Late Registration
After April 27, 2012
 
 
1. Both conference Days
(May 31st & June 1st)
2. May 31st only
3. June 1st Only




     
 
* How did you hear about this conference? Other:
 

Once you hit ‘submit,’ you will be redirected to a secure UM page to input your credit card information.

Special Services/Dietary Needs

If special arrangements are required for an individual with a disability or dietary need to attend this conference, contact Susan Hahn at (877) 686-6444 or shahn@med.miami.edu at least 15 days prior to the conference

CANCELLATION POLICY:

Cancellation must be made in writing. Refunds will be made only if written notice of cancellation is received prior to May 7th, 2012. A $85 fee is charged for all refunds. After this date, no refunds will be made. “No shows” are subject to the full course fee. In case the conference is cancelled due to insufficient registrations, a full tuition refund will be made.


For questions please feel free to contact conference planners at:  hihggapconf@med.miami.edu

Contact: Susan Hahn, MS, CGC
University of Miami Miller School of Medicine
John P. Hussman Institute for Human Genomics
1501 NW 10th Avenue, BRB-342(M-860)
Miami, Florida 33136
Phone: (877) 686-6444 (toll free)
Desk: (305) 243-2365
shahn@med.miami.edu