LECOM Hospital Day 2019 Registration Question Title * LECOM at Seton Hill Hospital Day presented on Thursday, April 4, 2019 and LECOM Erie Hospital Day presented on Friday, April 5, 2019Sponsored by the Lake Erie College of Osteopathic Medicine (LECOM)Please check one box or both boxes for attending LECOM Hospital Day as the registration is for both events. LECOM at Seton Hill Hospital Day: Thursday, April 4, 2019 from 10:00 a.m. to 1:00 p.m. LECOM Erie Hospital Day: Friday, April 5, 2019 from 10:00 a.m. to 1:00 p.m. Question Title * Contact Information Name and Credentials: * Hospital Representing: * Address: * Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Email Address: * Phone Number: * Question Title * Are you a LECOMT OPTI Hospital? Yes No Question Title * One (1) draped, 8-ft table with two (2) chairs will be provided. Will you require the use of an electrical outlet? Availability is limited, but we will try to accommodate. Yes No Question Title * Will you require floor space for display? Yes No Question Title * Will you be sending your display to LECOM at Seton Hill? Yes No Question Title * Contact person and phone number for day of event at LECOM at Seton Hill Hospital Day: Name: Phone Number: Question Title * LECOM at Seton Hill Hospital Day - Name of Representative/Credential/Title attending Name 1: Name 2: Name 3: Name 4: Question Title * Year of LECOM Graduation (if applicable) Year 1: Year 2: Year 3: Year 4: Question Title * Rotations/Clerkships Offered: Question Title * Residencies/Fellowships Offered: Question Title * Will you be attending the luncheon at LECOM at Seton Hill? Yes No Number attending luncheon Question Title * If not attending the luncheon at Seton Hill Hospital Day, will you require a box lunch? Yes No Number needed: Question Title * Will you be sending your display to LECOM Erie for transport to the event site at the Zem Zem Shrine Club? Yes No Question Title * LECOM Erie Hospital Day - Name of Representative/Credential/Title attending: Name 1: Name 2: Name 3: Name 4: Question Title * Year of LECOM Graduation (if applicable) Year 1: Year 2: Year 3: Year 4: Question Title * Rotations/Clerkships Offered: Question Title * Residencies/Fellowships Offered: Please complete the registration for return no later than March 8, 2019. Interested hospitals/institutions are encouraged to register early as we follow a “first- come, first-served” policy for registration. The Seton Hill site is limited STRICTLY to forty(40) hospitals with one (1) table maximum per hospital. A confirmation email will be sent upon receipt of your registration.Questions specific to LECOM at Seton Hill Hospital Day should be emailed to Heather Blackburn .Questions specific to LECOM Erie Hospital Day should be addressed to Laurie Mahoney at lmahoney@lecom.edu. Done