4th Annual Fellows for Life Conference Registration
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Thank you for registering for the 4th Annual Fellows for Life Conference Weekend, October 15-17, 2010 at the Sheraton Inner Harbor in Baltimore, Maryland.

Registration will close October 1, 2010. The cost of registration is $30 for current Fellows and $50 for Fellows for Life. Guests may register for $150. As a not-for-profit organization, this Conference would not be possible without the financial support of attendees and sponsors. Registration fees contribute to conference costs associated with meals and event materials. Payment information is at the bottom of this form.

Additional conference details will be available fall 2010. A member of the staff will follow-up with you in 1-2 weeks regarding your registration and any questions you may have. If you have any urgent questions, please contact Meghan Johnson, National Program Director, at mjohnso9@bidmc.harvard.edu.

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1. First Name

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2. Last Name

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3. Primary Affiliation (Academic or Professional)

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4. Name exactly as you would like it to appear on your name badge.

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5. City

6. State (if in U.S.)

7. Country (if not U.S.)

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8. Email

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9. To assist with networking, we will be including a list of Conference attendees in the materials provided. Please indicate what information we may provide in printed materials.

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10. Program Location Where You Were a Fellow (Fellows who served as U.S. and Lambarene Fellows should indicate both programs)

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11. Fellowship Year (Fellows who served as U.S. and Lambarene Fellows should indicate both years)

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12. Occupational Field

13. Have you attended the Fellows for Life Conference before (check all that apply)?

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14. Please indicate which events you plan to attend. This schedule is tentative, further details will be available closer to the conference.

15. We are seeking volunteers to help with the Conference Weekend. If you are interested in volunteering, please indicate what you might be willing to help with:

16. If you live the Baltimore area, would you be willing to host an out of town Fellow or Fellow for Life at your home on Friday and/or Saturday night?

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17. Do you have any dietary restrictions?

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18. Do you have any mobility concerns we should know about?

19. How did you hear about the Fellows for Life Conference? (Check all that apply)

20. Additional Comments

REGISTRATION FEE
The registration fee for the conference, which will help to cover the cost of the conference, is $30 for Current Fellows, $50 for Fellows for Life, and $150 for Guests. When you submit this registration form, you will be re-routed to ASF's online donation page. Even if you decide not to pay online, we will still receive your registration, and look forward to receiving your check via regular mail. To pay by check: Send checks made payable to The Albert Schweitzer Fellowship to ASF, 330 Brookline Ave (BR), Boston, MA 02215. Please note "FFL Conference" on the check.