EMERGENCY MEDICINE LEADERSHIP SUMMIT

2021 Summit Registration

Question Title

* 1. First Name

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* 2. Last Name

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* 3. Practice/Hospital

Name

State (if not in Maine)

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* 4. Check the category that best applies to you:

I am an emergency department director.

I am in a leadership position in my emergency department.

I am interested in becoming an emergency department leader/director.

I work in the emergency department

I work in emergency services (Urgent Care, EMS, etc.)

Other (please specify)

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* 5. Credentials or Degree

MD / DO - FACEP

MD / DO

PA-C

APRN / RN

Emergency Medicine Administrator

Other (please specify)

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* 6. Register me for: (check all that apply)

Emergency Department Workforce Issues
March 5, 2021 - 2:00 pm to 3:30 pm
Dr. Mark Rosenberg, MD, FACEP (ACEP President) and Susan Sedory, MA, CAE (ACEP Executive Director)

Advocacy - Connecting with Stakeholders and Policy Makers for Change
March 12, 2021 - 3:00 pm - 4:00 pm
Tony Cirillo, MD, FACEP

Innovations in Rural Emergency Department Staffing
March 19, 2021 - 4:00 pm - 5:00 pm
Speaker TBA

EMERGENCY MEDICINE LEADERSHIP SUMMIT

2021 Summit Registration

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. Practice/Hospital

Question Title

* 4. Check the category that best applies to you:

Question Title

* 5. Credentials or Degree

Question Title

* 6. Register me for: (check all that apply)

Question Title

* 7. Comment or Note: