Symposium 2012 Registration
Complete this form to register for the 6th Annual Sickle Cell Disease Research and Educational Symposium and Annual National Sickle Cell Disease Scientific Meeting
Memorial Healthcare System
Hollywood, Florida, USA
WEDNESDAY, FEBRUARY 29, 7AM- FRIDAY, March 2, 2012- 2PM
Registration includes:
Access to the conference, conference educational materials, daily breakfast, daily lunch, and Wednesday reception.
Registration Cancellations:
- Cancellations prior to February 8, 2012 will incur a $25 cancellation fee
- There will be no refunds after February 8, 2012
Hotel registration
Westin Diplomat Resort and Spa
3355 South Ocean Drive
Hollywood, FL 33019
954-602-6000
http://www.starwoodmeeting.com/Book/sicklecell2012
Title
First Name
Middle Initial
Last Name
Email*
Retype Email*
Organization
Address
City
State
Zip
Phone*
Fax
Division
Department
Check all that apply
Please select your specialty
Other specialty
Registration*
Would you like CME or CEU credit certificate?
* No additional fee required.
*I would be interested in attending a Social Worker/Psychosocial Luncheon.
Type of Social Worker/Psychosocial Luncheon
Please select ALL topics you would be interested in
Special Food Requests
Special needs request
Would you be interested in attending a SCAPN pre-meeting session on “Neurologic Complications in the Adult with Sickle Cell Disease: Unexpected Losses”, on Tuesday Feb 28th? (There is no additional cost.)
Payment Method*
CC Type
Credit card#
Expiration Date
CV Code
Visa,MC,Discover - 3 number code on back
Amex - 4 digit code on front
Amex - 4 digit code on front
Security Code:
Enter Security Code:
