PHM 2018 Faculty Information

Thank you for your submission to Pediatric Hospital Medicine 2018  which will be held July 19-22, 2018 at the Marriott Marquis in Atlanta, Georgia. 
We require the following form to be completed by January 31, 2018.  The information you provide here will be used for the official publications, website and mobile guide.  We will also use this information to register you for the conference as a faculty member.  Please remember:  only the lead presenter will receive complimentary registration.  Please ensure all information provided is accurate.  If there is any change in your personal or academic information, please contact us as soon as possible.  We ask that you provide your assistant's information, if applicable, to be sure that all communications are received.  Please note:  we only require this information from the lead presenter.  All co-presenters will be required to fill out a Conflict of Interest Form, which will be sent after all of the sessions are confirmed.
First name:

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* 1. First name:

Last name:

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* 2. Last name:

Professional Designation:

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* 3. Professional Designation:

Name desired on badge:

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* 4. Name desired on badge:

Mailing Address:

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* 5. Mailing Address:

City, State, Zip

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* 6. City, State, Zip

Phone:

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* 7. Phone:

Email address:

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* 8. Email address:

Academic Title (If applicable) :

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* 9. Academic Title (If applicable) :

Institution:

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* 10. Institution:

Institution City, State, Zip

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* 11. Institution City, State, Zip

What session type are you presenting?

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* 12. What session type are you presenting?

Undergraduate College:

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* 13. Undergraduate College:

Medical School:

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* 14. Medical School:

Residency:

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* 15. Residency:

Fellowship:

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* 16. Fellowship:

Board Certifications:

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* 17. Board Certifications:

Professional Society Memberships:

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* 18. Professional Society Memberships:

Committees and/or Boards:

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* 19. Committees and/or Boards:

Special Interests:

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* 20. Special Interests:

Are you a member of APA, AAP or SHM?  Choose all that apply.

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* 21. Are you a member of APA, AAP or SHM?  Choose all that apply.

Please enter any special needs requirements (dietary restrictions, wheelchair access, etc.)

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* 22. Please enter any special needs requirements (dietary restrictions, wheelchair access, etc.)

Please enter your assistant's information, if applicable.

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* 23. Please enter your assistant's information, if applicable.

Please provide a brief biography to be featured in PHM 2018 communications.

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* 24. Please provide a brief biography to be featured in PHM 2018 communications.

Please provide a picture (head-shot) to be featured in the PHM 2018 communications.

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* 25. Please provide a picture (head-shot) to be featured in the PHM 2018 communications.

JPEG, JPG file types only.
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If you have a Twitter account and would like to provide your handle here, we may include it in our social media promotions.

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* 26. If you have a Twitter account and would like to provide your handle here, we may include it in our social media promotions.

By completing this form and signing below, you accept the PHM 2018 Planning Committee's invitation to serve as a faculty member for Pediatric Hospital Medicine 2018 and commit to the deadlines outlined in your acceptance letter. Typing your name below will constitute a legal signature.

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* 27. By completing this form and signing below, you accept the PHM 2018 Planning Committee's invitation to serve as a faculty member for Pediatric Hospital Medicine 2018 and commit to the deadlines outlined in your acceptance letter. Typing your name below will constitute a legal signature.

If you have any questions, please contact Stephanie Blyskal at stephanie@academicpeds.org or call 703-556-9222.  We look forward to seeing you in Atlanta!

The PHM 2018 Planning Committee:


Dr. Jennifer O’Toole, Co-Chair, Pediatric Hospital Medicine 2018

University of Cincinnati, Cincinnati Children’s Hospital Medical Center


Dr. Lauren Solan, Co-Chair, Pediatric Hospital Medicine 2018

University of Rochester, University of Rochester Medical Center
 

Dr. Kris Rehm, Past Chair, Pediatric Hospital Medicine 2017

Vanderbilt University School of Medicine, Monroe Carell Jr. Children’s Hospital

 
Dr. Lindsay Chase

University of North Carolina, UNC Medical Center

 
Dr. Jeffrey Grill

University of Louisville, Norton Children’s Hospital

 
Dr. Kayce Morton

Cox Health Systems


Dr. Erin Shaughnessy

Phoenix Children’s Hospital
 

Dr. Geeta Singhal

Texas Children’s Hospital



Dr. Jeremy Yardley

Eastern Maine Medical Center



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