1998 Eleventh Annual Pediatric Critical Care Colloquium

Registration Form

Pre Registration Deadline: August 15, 1998

Eleventh Annual Pediatric Critical Care Colloquium

"Looking to the New Millennium"

September 16-20, 1998

Chicago, Illinois

Name (print or type)_______________________________________________

Institution________________________________________________________

Address____________________________________________________________

City____________________State__________ZIP__________Country________

Name preference for name tag_______________________________________

Daytime phone_____________________________FAX______________________

Email address______________________________________________________

Course fees: (American dollars only, please)

Registration (prior to 8/15) 300.00
Registration (received after 8/15) 350.00
Total fee: $ ______

Method of payment:
Check payable to: Hope Children's Hospital
Credit Card: ____Visa ____Mastercard

Credit Card #______________________________Expiration date__________

Signature___________________________________________________________

In order to ensure accommodations for all those interested in the following activities,
please indicate if you plan to attend, and the number attending.

Wednesday, September 16 Thursday, September 17
___Welcome reception
___# attending
____Lunch Committee meetings
Friday, September 18 Saturday, September 19
___Cubs game outing
___# attending
(there will be a small additional fee to this outing)
___Caribbean Dinner Cruise
___# attending

Mail or Fax Registration to:

Pediatric Critical Care Colloquium
Hope Children's Hospital, Division of Critical Care
4440 W. 95th St., Suite 3192H
Oak Lawn, IL 60453
Phone: (708) 346-5685 FAX: (708) 346-4712



Download an Adobe Acrobat version of these forms for printing: PCCCFORM.PDF

or...

To print this frame, click in this window, then choose print


Document created April 27, 1998; last modified (typgraphical error) March 16, 1999
http://pedsccm.org/ORG-MEET/PCCC98/Registration.html