NAFP Student/Resident Retreat

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Name* This field is required.

First Name

Last Name

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Title* This field is required.

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Title* This field is required.

MD

DO

MS

OMS

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Medical school/Residency program* This field is required.

6

Year in Medical school/Residency* This field is required.

7

AAFD IDif applicable

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E-mail* This field is required.

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Phone Number* This field is required.

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I will attend:* This field is required.

Friday Sessions

Saturday Sessions

Sunday Sessions

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I plan to submit an abstract and present a poster at the meeting.* This field is required.(visit nvafp.com for details and application)

YESNO

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I would like to apply for a travel scholarship

YESNO

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Travel scholarship info

Your full legal name (exactly as shown on a government issued ID)

Date of birth

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Travel scholarship essayPlease write a 200 word essay on why you are interested in family medicine and why you deserve this travel scholarship

0/0

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I would like to share a room with the following students/residents

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Acknowledgement, Waiver and Release Related to COVID-19* This field is required.The Nevada Academy of Family Physicians (NAFP) has implemented enhanced health and safety measures in connection with its 2022 Winter CME Meeting. In addition, the NAFP is requiring all attendees, exhibitors, and staff to be fully vaccinated against COVID-19 before attending. While vaccinations, observance of safety protocols, and exercise of personal discipline may reduce risk, however, an inherent risk of exposure to COVID-19 does remain in connection with any public gathering. Accordingly, as a condition of your attendance at this event, please click the box below to indicate your acknowledgement of and agreement to the following: I understand that COVID-19 is an extremely contagious disease that can lead to severe illness and death. I acknowledge my own desire and voluntary choice to travel to and participate in the 2022 Winter CME Meeting. I assume responsibility for my own well-being and accept the risk of being exposed to, contracting, and/or spreading COVID-19 in order to attend. Specifically, I assume all risks and accept sole responsibility for any injury (including, but not limited to, personal injury, illness, disability, and death) that I may experience in connection with attending, and I hereby waive, release, and hold harmless the NAFP, their employees, agents, contractors, and representatives from any claims, liabilities, actions, damages, losses, costs, or expenses of any kind arising out of or relating to my attendance. I agree to follow all instructions and safety precautions posted or provided by the NAFP, the event venue, or any governing authority during my attendance at the event. I understand and agree that my failure to do so may result in my being excluded from the event without refund, reimbursement, or other remuneration.

I am vaccinated, and I have read and agree to the NAFP’s COVID-19 Acknowledgement, Waiver and Release