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IFM Conf - Permanente Physicians

Our Price: $625.00

Registrant Information

Pre-Title:

First Name*:

Middle Initial:

Last Name*:

Suffix:

For "Other" suffix, please note in Remarks section below.

Post-Title*:

For "Other" post-title, please note in Remarks section below.

Badge Name:

Enter nickname or leave blank if same as above

Kaiser Region:

Non-Kaiser Facility or Practice*:

i.e. Group Health Cooperative. Please enter "NA" here if you are a Kaiser affiliate.

Facility City:

Facility State:

Remarks:

*Enter remarks or custom post-title here.

How did you hear about this meeting:

For "Other," please note in Remarks

Hotel Reservation

Check-In Date:

Use format MM/DD/YYYY; date you will arrive

Check-Out Date:

Use format MM/DD/YYYY; date you will depart

Bed Request:

Number of beds - Enter 1 or 2; hotel cannot guarantee

Room Type:

Arrival and Departure dates need to be entered in field. Room reservation cannot be confirmed without this info.

# of Rooms:

Enter the number of rooms you are requesting

Special Request:

*Enter special room requests. Indicate if reserving more than one room, or if sharing a room with another attendee. Hotel cannot guarantee special requests.

Full Guest Names In This Room

Guest 1 or Self:

Guest 1 Age:

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Guest 2:

Guest 2 Age:

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Guest 3:

Guest 3 Age:

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Guest 4:

Guest 4 Age:

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