Registration-FacultyResidents

Faculty and Resident Registration

Please note - There is no registration fee for course attendees.

We thank you for your interest if you have any questions pleast contact Rebecca Smith at Rebecca.Smith@CoxHealth.com

Name As it appears on photo ID

Program Residency program or affiliated hospital

Arrival Date Day/Month/Year

Departure Date Day/Month/Year

Travel Method Flying or Driving

Date of Birth If flying

Preferred Airport If flying

Frequent Flyer Number If flying

Shirt Size

Scrub Size

Phone Number

E-mail Address

Food Allergies

Thursday Activity

Friday Activity

Name of Significant Other If accompanying you

Name of Children If accompanying you

This event is made possible through sponsor support, your email information may be disseminated to assist the furtherment of this course

Ozarks Neuroscience Education Clinic