Exit this survey 2017 Shock Symposium Registration To register for this program, please provide the following information. Please allow time to complete this registration form in its entirety. If you exit to complete at a later time, you will need to start over.Once this form is completed, click done and you will be redirected to a secure webpage to complete your payment with a credit card. You MUST register using the attendees name, contact information and their email address. If you complete the form multiple times with the same name and email address it will be considered a duplicate and all but one will be deleted. If you have any questions please contact Nia Flick at Nia.Flick@heart.org.By registering for the 2017 Shock Symposium you will be automatically added to professional education mailing list to keep you informed of additional educational programs. If you wish, you will be able to unsubscribe at anytime. Question Title * 1. Please type your information with appropriate upper and lower case characters. Please do not use all caps or all lower case as this information will be used as it is entered for your name badge. You must complete all the fields in this question in order to move forward - if you would like to leave a field blank please indicate so by typing n/a in the field. First Name Middle Name/Initial Last Name Credentials/Degree Job Title Affiliation (Please do not abbreviate) Address City State Zip code Email Address Telephone (Day Time Number) Question Title * 2. EMERGENCY CONTACT: Please list a personal contact who we should reach in the unlikely event of an on-site or medical emergency. First Name Last Name Contact Relationship Contact Telephone Question Title * 3. If you are completing this registration form on behalf of the registrant above please provide your information below: Name Email Address Phone Number Question Title * 4. Have you previously registered for an American Heart Association/American Stroke Association course? Yes No Question Title * 5. Primary Classification Administrator Certified Professional in Health Care Quality EMT/Paramedic Non-Healthcare Professional Nurse Nurse Practitioner Occupational Therapist Other Pharmacist Physician Physician’s Assistant Registered Dietitian Research Scientist Respiratory Therapist Technician/Technologist Question Title * 6. Secondary Classification Administrator Certified Professional in Health Care Quality EMT/Paramedic Non-Healthcare Professional Nurse Nurse Practitioner Occupational Therapist Other Pharmacist Physician Physician’s Assistant Registered Dietitian Research Scientist Respiratory Therapist Technician/Technologist Question Title * 7. Customer Segment Student Early Career Other Question Title * 8. Primary Specialty Administration Anesthesia Cardiology Critical Care Emergency Medicine Epidemiology Family Practice Hypertension Internal Medicine Neuro/NeuroScience Other Pharmaceutical Industry Pharmacology Pre-hospital Rehab/Exercise Surgery Thrombosis Vascular Medicine Other (please specify) Question Title * 9. Secondary Specialty Administration Cardiology Emergency Medicine Epidemiology Family Practice Hypertension Internal Medicine Neuro/NeuroScience Other Pharmaceutical Industry Pharmacology Pre-hospital Rehab/Exercise Surgery Thrombosis Vascular Medicine Question Title * 10. If you have any special dietary requirements, or if you require auxiliary aids or services as identified in the Americans with Disabilities Act, please note your needs below. We encourage participation by all individuals. Question Title * 11. CROWD NOTICE—PHOTO/FILM RELEASEBe advised that photographs and film will be taken throughout these events. These photos and film will be used for a variety of purposes by the discretion of the American Heart Association/American Stroke Association and/or Beth Israel Deaconess Medical Center. Potential examples include use in collateral, presentations, online use and all types of media. No compensation will be given. If you have any concerns, please speak with an American Heart Association/American Stroke Association staff member immediately.I understand what I have read with regard to the crowd notice-photo/film release. Yes No Other (please specify) Next
