Henry Ford + MSU Children's Health Symposium: Teaching Beyond the Clinic - Shaping Learners, Strengthening Teachers
Registration Form
Join us Saturday, October 17th, from 8:00am - 1:00pm, at Ford Hall (located in Henry Ford Hospital)
Breakfast will be served at 7:15am
Name
*
First Name
Last Name
Title
*
Mr.
Mrs.
Ms.
Dr.
Other
Suffix
M.D.
D.O.
PhD
MS
RN
Other
Professional Title
*
Senior Staff Physician
Department Chair
Residency Program Director
Clerkship Director
Other
Institution/Hospital Affiliation
*
Henry Ford Main (Detroit)
Henry Ford Jackson
Henry Ford Macomb
Henry Ford Wyandotte
Henry Ford St. John
Henry Ford Madison Heights/Warren
Henry Ford Genesys
Henry Ford Providence
Other
Breakfast will be available at 7:15a, please indicate whether you plan on joining us
*
Yes, I will be there for breakfast
NO, I will not be there for breakfast
Please list any dietary restrictions you may have
*
No dietary restrictions
Gluten free
Halal
Kosher
Vegan
Vegetarian
Other
Do you intent to pursue CME for this event, if available?
*
Yes
No
If you require a reasonable accommodation in order to participate, please specify the type(s) of accommodations you will need
*
None needed at this time
Accessible seating area for wheelchair or scooter
ALC Interpreting Services
Real-Time Closed Captioning
Wheelchair
Other
Will you need valet parking for this event?
*
Yes, I will need valet parking
No, I have access to HFH parking onsite
Additional Comments
Submit
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