2011 RAD-AID Conference Registration

1. Sign-Up Information

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Question Title

* 1. We are pleased that you are coming to the RAD-AID Conference on Radiology for Developing Countries on Sunday, October 30, 2011 at Johns Hopkins in Baltimore. This free (donation optional) conference will bring together leaders from radiology, business, philanthropic foundations, academic institutions, and NGOs to discuss solutions to developing countries' shortages of imaging services. Agenda includes (1) health care and imaging strategies for limited resource regions, (2) technology innovation & solutions, (3) international economic development, finance and social entrepreneurship for medical imaging in the developing world, and (4) educational training strategies. Please provide the following information to complete your reservation:

Name: *

Company:

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

Email Address: *

Phone Number:

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* 2. Please describe yourself by checking all that apply to you:

Public Health Specialist

Private Sector (Finance and Banking)

Private Sector (Technology, Manufacturing, Services)

Non-Governmental Organization (NGO)

Government Institution

Academic Institution

Radiologist

Surgeon

General Medicine Physician

OB-GYN

Orthopedics

Emergency Medicine Physician

Internal Medicine Subspecialist

Pediatrician

Family Medicine

Nurse or Nurse Practitioner

Physician Assistant

Radiologic Technologist (RT)

Radiologist Assistant (RA)

Radiology Practitioner Assistant (RPA)

Attorney

Medical Student

Undergraduate Student

Graduate Student

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* 3. Please indicate your level of interest in each of the following specialty areas that will be addressed at the conference.

	Very Interested	Somewhat Interested	Neutral	Somewhat Not Interested	Not Interested	Need more information
1. Clinical Radiology for training overseas health personnel	1. Clinical Radiology for training overseas health personnel Very Interested	1. Clinical Radiology for training overseas health personnel Somewhat Interested	1. Clinical Radiology for training overseas health personnel Neutral	1. Clinical Radiology for training overseas health personnel Somewhat Not Interested	1. Clinical Radiology for training overseas health personnel Not Interested	1. Clinical Radiology for training overseas health personnel Need more information
2. Technology Solutions for Imaging in the developing world	2. Technology Solutions for Imaging in the developing world Very Interested	2. Technology Solutions for Imaging in the developing world Somewhat Interested	2. Technology Solutions for Imaging in the developing world Neutral	2. Technology Solutions for Imaging in the developing world Somewhat Not Interested	2. Technology Solutions for Imaging in the developing world Not Interested	2. Technology Solutions for Imaging in the developing world Need more information
3. Residencies, Education, and the Role of Residents in Assisting Developing Countries.	3. Residencies, Education, and the Role of Residents in Assisting Developing Countries. Very Interested	3. Residencies, Education, and the Role of Residents in Assisting Developing Countries. Somewhat Interested	3. Residencies, Education, and the Role of Residents in Assisting Developing Countries. Neutral	3. Residencies, Education, and the Role of Residents in Assisting Developing Countries. Somewhat Not Interested	3. Residencies, Education, and the Role of Residents in Assisting Developing Countries. Not Interested	3. Residencies, Education, and the Role of Residents in Assisting Developing Countries. Need more information
4. Business, Entrepreneurship, and Leadership Training for Developing Countries' health care providers.	4. Business, Entrepreneurship, and Leadership Training for Developing Countries' health care providers. Very Interested	4. Business, Entrepreneurship, and Leadership Training for Developing Countries' health care providers. Somewhat Interested	4. Business, Entrepreneurship, and Leadership Training for Developing Countries' health care providers. Neutral	4. Business, Entrepreneurship, and Leadership Training for Developing Countries' health care providers. Somewhat Not Interested	4. Business, Entrepreneurship, and Leadership Training for Developing Countries' health care providers. Not Interested	4. Business, Entrepreneurship, and Leadership Training for Developing Countries' health care providers. Need more information
5. Radiology Role in Public Health Initiatives: Adapting radiology for public health such as TB monitoring, AIDS infection, cancer screening and other population issues	5. Radiology Role in Public Health Initiatives: Adapting radiology for public health such as TB monitoring, AIDS infection, cancer screening and other population issues Very Interested	5. Radiology Role in Public Health Initiatives: Adapting radiology for public health such as TB monitoring, AIDS infection, cancer screening and other population issues Somewhat Interested	5. Radiology Role in Public Health Initiatives: Adapting radiology for public health such as TB monitoring, AIDS infection, cancer screening and other population issues Neutral	5. Radiology Role in Public Health Initiatives: Adapting radiology for public health such as TB monitoring, AIDS infection, cancer screening and other population issues Somewhat Not Interested	5. Radiology Role in Public Health Initiatives: Adapting radiology for public health such as TB monitoring, AIDS infection, cancer screening and other population issues Not Interested	5. Radiology Role in Public Health Initiatives: Adapting radiology for public health such as TB monitoring, AIDS infection, cancer screening and other population issues Need more information
6. Radiology's role in epidemic detection and response	6. Radiology's role in epidemic detection and response Very Interested	6. Radiology's role in epidemic detection and response Somewhat Interested	6. Radiology's role in epidemic detection and response Neutral	6. Radiology's role in epidemic detection and response Somewhat Not Interested	6. Radiology's role in epidemic detection and response Not Interested	6. Radiology's role in epidemic detection and response Need more information

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* 4. Please give us any comments you would like RAD-AID officials to read that will help in planning the conference.

Thank you for Registering. If you have any questions about the conference, please email us at info@rad-aid.org