16th Annual Chronic Illness and Disability Conference: Transition from Pediatric to Adult-based CareTexas – Broadcast Site Registration Deadline: Monday, September 25, 2017 Baylor Colleg
Trang 118th Annual Chronic Illness and Disability Conference: Transition from Pediatric to Adult-based Care
Broadcast Site Registration
Baylor College of Medicine, One Baylor Plaza, MS: BCM 155, Houston, Texas 77030 | T: 713.798.8237 | E:
cme@bcm.edu
Rev 07.2017
Trang 218th Annual Chronic Illness and Disability Conference: Transition from Pediatric to
Adult-based Care
Broadcast Site Registration Thursday, October 5, 2017
8:00 am – 12:15 pm (CST)
1:15 pm – 4:15 pm (CST)
Friday, October 6, 2017
8:00 am – 12:15 pm (CST) 1:00 pm – 4:00 pm (CST)
Baylor College of Medicine, One Baylor Plaza, MS: BCM 155, Houston, Texas 77030 | T: 713.798.8237 |
E: cme@bcm.edu
Rev 07.2017
Trang 316th Annual Chronic Illness and Disability Conference: Transition from Pediatric to Adult-based Care
Texas – Broadcast Site Registration
Deadline: Monday, September 25, 2017
Baylor College of Medicine, One Baylor Plaza, MS: BCM 155, Houston, Texas 77030 | T:
713.798.8237 | E: cme@bcm.edu
Trang 41 Complete the following information to register as a broadcast site
2 Return the completed form by the deadlineto ensure your Organization is registered as a broadcast site This conference will not be archived
DSHS/MCHB-Funded Organization or UCEDD
Institution Name
Mailing Address
City, State, Zip
The broadcasting technical specifications have been reviewed and will be tested on the appropriate testing
date? Yes No
Our Organization commits to the following:
1 Receiving broadcast both days of the conference
2 Appointing a site coordinator who will be responsible for reporting attendance
3 Appointing a site technical coordinator who will be responsible for on-site technical issues
4 Guaranteeing a minimum of 5 individuals in attendance from the Organization each day
# Attendees
(NOTE: If this number changes, please re-send this form via email or fax with the updated estimated number by Thursday, September 28 th )
5 Registration fee payment of $150.00
(Separate registration and payment is required for each broadcast site Multiple sites per registration will
no longer be accepted.)
Check (Made payable to: Baylor College of Medicine)
Credit Card VISA MasterCard AMEX Discover
Signature
Person completing registration:
Mailing Address Same as Organization address
City, State, Zip
Submit to cme@bcm.edu or via fax to 713.798.7955
Baylor College of Medicine, One Baylor Plaza, MS: BCM 155, Houston, Texas 77030 | T: 713.798.8237
| E: cme@bcm.edu