Medicine as Moral Practice Conference Registration Form

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Full Name* This field is required.

First Name

Last Name

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E-mail* This field is required.

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Phone Number* This field is required.

Area Code

Phone Number

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Current university level* This field is required.If you are not currently affiliated with a university (e.g. in between medical school and residency), please indicate the most recent level of medical training you've completed.

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Current institution or organization* This field is required.If you are not currently affiliated with a university (e.g. in between medical school and residency), please indicate the institution or organization at which you completed your most recent level of medical training.

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If you are in residency or have completed your training, indicate your specialty here.* This field is required.

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Resume* This field is required.Please upload a pdf version only.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Conference Lodging* This field is required.The Medicine as Moral Practice Conference is FREE, inclusive of food (breakfast, lunch, dinner) and conference materials. Discounted accommodations at the AC Hotel Irvine (Marriott) are available at $350 total for two nights. Participants who attend or have attended medical programs at the universities listed below may secure partial or complete funding to cover their travel and lodging expenses. For more information, please select the university at which your are currently a physician trainee.

Stanford University

Duke University

Johns Hopkins University

I'm not affiliated with any of the universities listed above.

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For participants affiliated with Stanford UniversityPlease indicate your desired travel and lodging arrangements below. Select all that apply.

Air travel: Flight (reimbursable up to $150 only) + airport transfer (reimbursable up to $50)

Long Drive from Palo Alto to Irvine: Gas expenditures (reimbursable up to $100)

Lodging for August 9 (Friday) at AC Hotel Irvine - King w/ pull-out sofa (fully covered by Zephyr Institute)

Lodging for August 10 (Saturday) at AC Hotel Irvine - King w/ pull-out sofa (fully covered by Zephyr Institute)

Lodging for 2 nights at AC Hotel Irvine - King w/ pull-out sofa (fully covered by Zephyr Institute)

None

Other

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For participants affiliated with Johns Hopkins UniversityPlease indicate your desired travel and lodging arrangements below. Select all that apply. Instructions on next page.

Flight (fully covered) + airport transfer (fully covered)

Lodging for August 9 (Friday) at AC Hotel Irvine - King w/ pull-out sofa (fully covered)

Lodging for August 10 (Saturday) at AC Hotel Irvine - King w/ pull-out sofa (fully covered)

Lodging for 2 nights at AC Hotel Irvine - King w/ pull-out sofa (fully covered)

None

Other

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Instructions for Johns Hopkins University participantsFlight and airport transfer are fully reimbursable. Discounted rooms at the AC Marriott is also reimbursable. Please use this link to reserve your room at the AC Hotel Irvine directly: http://bit.ly/moral-medicine-marriott-discounted-booking. You may also book your hotel room by reaching out to Lauren Widger (949-471-8715, lauren.widger@achotelirvine.com) and mentioning "Medicine as a Moral Practice Conference." She will give you discounted rates too. By selecting "I agree" below, you acknowledge that you are responsible for booking your flights, transport and accommodations, and that you aren't guaranteed a flight, transportation or room until you do so. And all reimbursement questions and requests should be sent to mchisol1@jhmi.edu.

I agreeI disagree

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For participants affiliated with Duke UniversityPlease indicate your desired travel and lodging arrangements below. Select all that apply. Instructions on next page.

Flight (fully covered) + airport transfer (fully covered)

Lodging for August 9 (Friday) at AC Hotel Irvine - King w/ pull-out sofa (fully covered)

Lodging for August 10 (Saturday) at AC Hotel Irvine - King w/ pull-out sofa (fully covered)

Lodging for 2 nights at AC Hotel Irvine - King w/ pull-out sofa (fully covered)

None

Other

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Instructions for Duke University participantsFlight and airport transfer are fully reimbursable. Discounted rooms at the AC Marriott is also reimbursable. Please use this link to reserve your room at the AC Hotel Irvine directly: http://bit.ly/moral-medicine-marriott-discounted-booking. You may also book your hotel room by reaching out to Lauren Widger (949-471-8715, lauren.widger@achotelirvine.com) and mentioning "Medicine as a Moral Practice Conference." She will give you discounted rates too. By selecting "I agree" below, you acknowledge that you are responsible for booking your flights, transport and accommodations, and that you aren't guaranteed a flight, transportation or room until you do so. And all reimbursement questions and requests should be sent to farr.curlin@duke.edu.

I agreeI disagree

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Please indicate if you would like to avail of our discounted group rate at the AC Hotel Irvine (Marriott).The room type is a King with a pull-out sofa.

Yes, I want to reserve a room for $169++/night

I do not need accommodations.

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Hotel Reservation InstructionsThank you! You may use this link to reserve your room at the AC Hotel Irvine directly: http://bit.ly/moral-medicine-marriott-discounted-booking. You may also book by reaching out to Lauren Widger (949-471-8715, lauren.widger@achotelirvine.com) and mentioning "Medicine as a Moral Practice Conference." She will give you discounted rates too. By selecting "I agree" below, you acknowledge that you are responsible for booking your accommodations and that you aren't guaranteed a room until you do so.

I agreeI disagree

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Thank you. A member of our team will be in touch shortly to confirm your university affiliation and provide additional travel & lodging stipend information.

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Is there anything else you'd like us to know?Indicate here if you have any special dietary restrictions or any requests pertaining to your travel & accommodations. While we can't guarantee we can accommodate all requests, we will try to do so.