2012 Convocation of Southern State Epidemiologists

Registration Form

 
The state of West Virginia is pleased to host and welcome you to the 2012 CSSE meeting January 27-30, 2013. There is no registration fee.

For our out-of-state guests, all meals on the agenda are included but the one Tuesday evening. Thus, your travel expenses are projected to be transportation, lodging and one meal.

All attendees should complete the following registration form by January 10,2013, if you plan on attending.

Before completing the registration form below please write the following contact information down, in the event you have questions about this event or need to cancel your reservation: Dr. Loretta Haddy, WV State Epidemiologist & OEPS Director (304) 558-5358; loretta.e.haddy@wv.gov. A draft agenda is posted online at www.dhhr.wv.gov/OEPS under CSSE. You will also find hotel and airport information posted there.

(For WV Representatives Only) Depending on the number of out-of-state guests that may be attending, you may need to make your own meal arrangements. The Marriott has a buffet luncheon downstairs for $14 per person and the mall has plenty of options across the street for your convenience.
*
1. Name:
*
2. Position / Title:
*
3. State/Location you are representing:
*
4. E-mail address:
*
5. Mailing address:
*
6. Office phone:
7. Cellular phone (optional)
8. Emergency contact person & phone:
*
9. Registration requested:
*
10. Meal needs
*
11. Are you willing to lead a discussion at the meeting?
If you are willing to lead a disussion at the CSSE meeting, someone from the WV Office of Epidemiology (OEPS) and Prevention Services will be contacting you soon.
Thank you for taking time to register for the 2012 CSSE Meeting. The WV OEPS will be staying in contact with you in the weeks to come. We look forward to seeing you in January.
Powered by SurveyMonkey
Check out our sample surveys and create your own now!