Please complete this form for each person who will attend.
Online registration will close July 5,2018

* 1. First Name

* 2. Last Name

* 3. Email

* 4. Phone Number

* 5. Which Practice Innovation Initiative are you participating in?

* 6. Organization Type

* 7. Are you representing more than one clinic or practice site?

* 8. If applicable, please select which SIM practice sites you are representing. (For multi-site practice, please list all the sites.)

* 9. If applicable, please select which TCPi practice site you are representing. (For multi-site practice, please list all the sites.)

* 10. If applicable, Please select which Practice Transformation Organization you are representing.

* 11. Please list the name of your Organization (This will appear on your name tag.)

* 12. If applicable, please list your Credentials e.g. MD,RN, etc. (This will appear on your name tag.)

* 13. What is your Role (s) within your organization? 

* 14. Please list any dietary restrictions or allergies? 

* 15. Please indicate if you have any need for auxiliary aids or special assistance service. 

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