registration form course... · 2020. 7. 16. · fax this form to: 847/228-5059. mail this form with...
TRANSCRIPT
AAP VIP Network QI Virtual Course:
"QI Bootcamp for Hospitalists"
September 24, 202012:30-4:30pm CT
REGISTER USING ONE OF THE FOLLOWING OPTIONS:Online at: shop.aap.org/QIbootcampCall toll-free: 866/843-2271, option 3 Outside the United States and Canada, call 630/626-6000, option 3Fax this form to: 847/228-5059Mail this form with payment to:American Academy of Pediatrics/RegistrationP.O. Box 776442Chicago, Illinois 60677-6442
Registration Form
PLEASE TYPE OR PRINT
NAMEFIRST LAST(SURNAME) MD,DO,OTHER(SPECIFY)
ADDRESS
CITY/STATE/PROVINCE
ZIPCODE/POSTALCODE/COUNTRY
CELL NUMBER
E-MAILADDRESS AAPID#(REQUIREDTORECEIVEIMPORTANTPRE-COURSEINFORMATIONANDUPDATES)
PLEASEINDICATEANYSPECIALNEEDS(E.G.,BREASTFEEDINGACCOMMODATIONS,DIETARYRESTRICTIONS/ALLERGIES,PHYSICALDISABILITIES).
PAYMENT INFORMATION Full payment must accompany this form. Please indicate method of payment below:
Charge it:
CARDNUMBER
EXPIRATIONDATE
PRINTNAMEASITAPPEARSONCARD
Or checks may be made payable to the American Academy of Pediatrics.
CHECK NUMBER AMOUNT
(US Registrants Only) Please do not send currency.
REGISTRANT FEES (U.S. Currency) $ 100.00
CancellationsCourse cancellations must be received in writing ([email protected]) by July 10, 2020 to receive a refund. An administrative charge of $50 will be deducted.
Your registration will be confirmed. Please contact AAP Registration if you donot receive a confirmation within 14 days. The AAP cannot be responsible forexpenses incurred by an individual who is not confirmed and for whom space isnotavailableat this course. Costs incurred, such as airline or hotel penalties, are the responsibility of the individual. The AAP reserves the right to cancel a course due to unforeseen circumstances or limit enrollments, should attendance exceed capacity.
EMPLOYER/INSTITUTION NAME
EMERGENCY CONTACT NAME/PHONE
AAP Fellows/Candidate Members/International
Nonmember Physicians
Questionnaire
How would you describe the stage of your professional career in Pediatrics?
☐ Early Career Physician (0-6 years)
☐ Mid-Career Physician (7-12 years)
☐ Advanced/Late Career Physician (more than 12 years)
Do you hold a quality improvement (QI) leadership role at your institution?
☐ Yes
☐ No
What QI leadership role(s) do you hold at your institution?
Are you a member of the American Academy of Pediatrics Value in Inpatient Pediatrics (VIP) Network?
☐ Yes
☐ No