uc_11111821_Keeping_It_Real_Conference_HIV_Prevention_in_2011_New

uc_11111821_Keeping_It_Real_Conference_HIV_Prevention_in_2011_New_Possibilities

1. Welcome

Thank you for using the Pennsylvania/MidAtlantic AIDS Education and Training Centers Online Registration Site.

Please complete the following information. When you have successfully registered, you will be taken to a confirmation page.

You are registering for the following event: Host (LPS): UC

Name of program: Keeping It Real Conference: “HIV Prevention in 2011: New Possibilities”

Program ID: 11111821

Location of program: Wright State University, Student Union Building, 3640 Colonel Glenn Hwy, Dayton, OH 45435

Date of program: 11/18/2011

Any special instructions about program (for example, if there is a charge):

Registration Fee – $15.00
Please submit check payable to University of Cincinnati Physicians Company and include “AETC 1118” in the subject line. Mail the check to: University of Cincinnati Medical Center, Holmes Building, 200 Albert Sabin Way, ML 0405, Cincinnati, OH 45267-0405, Attention: Cathy Siemer, AETC-Room 3105.

To pay by credit card either call or email Cathy Siemer at 513-584-7535 or siemercy@uc.edu.

For questions regarding Nursing CE, please contact: Yolanda Wess at 513-584-2422

If you have any questions regarding the program, please contact:
Name of contact person: Nancy Peter
Telephone number: 513-584-1488
Email address: nancy.peter@uc.edu

If you have any technical difficulties with this site and the registration process, please contact:
Name of contact person: David Korman
Email address: dmkorman@gmail.com

Thank you.

Please complete the following for your PREFERRED CONTACT INFORMATION. If a question is not applicable, please enter "NA." Name:
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uc_11111821_Keeping_It_Real_Conference_HIV_Prevention_in_2011_New_Possibilities

1. Welcome

*
1. What is your last name?

*
2. What is your first name?

3. What is your title?

*
4. IF available in your discipline, are you interested in obtaining educational credit for this event?

*
5. Please complete the following for your PREFERRED CONTACT INFORMATION. If a question is not applicable, please enter "NA."

6. Please state your 10 digit telephone number (includes area code, but no spaces or non-numerical characters).

*
7. Please state the last four digits of your Social Security Number. (Used to create a unique identifier.)

*
8. In what month were you born? (Used to create unique identifier.)

*
9. On what date of the month were you born? (Used to create a unique identifier.)

*
10. Please state your Primary Professional Discipline. (Select one.)

*
11. Please indicate your Primary Function Role. (Select one.)

*
12. Please state your Principal Employment Setting. (Select one.)

uc_11111821_Keeping_It_Real_Conference_HIV_Prevention_in_2011_New_Possibilities

1. Welcome

*1. What is your last name?

*2. What is your first name?

3. What is your title?

*4. IF available in your discipline, are you interested in obtaining educational credit for this event?

*5. Please complete the following for your PREFERRED CONTACT INFORMATION. If a question is not applicable, please enter "NA."

6. Please state your 10 digit telephone number (includes area code, but no spaces or non-numerical characters).

*7. Please state the last four digits of your Social Security Number. (Used to create a unique identifier.)

*8. In what month were you born? (Used to create unique identifier.)

*9. On what date of the month were you born? (Used to create a unique identifier.)

*10. Please state your Primary Professional Discipline. (Select one.)

*11. Please indicate your Primary Function Role. (Select one.)

*12. Please state your Principal Employment Setting. (Select one.)

*
1. What is your last name?

*
2. What is your first name?

*
4. IF available in your discipline, are you interested in obtaining educational credit for this event?

*
5. Please complete the following for your PREFERRED CONTACT INFORMATION. If a question is not applicable, please enter "NA."

*
7. Please state the last four digits of your Social Security Number. (Used to create a unique identifier.)

*
8. In what month were you born? (Used to create unique identifier.)

*
9. On what date of the month were you born? (Used to create a unique identifier.)

*
10. Please state your Primary Professional Discipline. (Select one.)

*
11. Please indicate your Primary Function Role. (Select one.)

*
12. Please state your Principal Employment Setting. (Select one.)