NYS AAP Annual Advocacy Day - March 5, 2014 - REGISTRATION FORM

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First Name:
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Title (MD, FAAP, PhD, etc.):
AAP NY Chapter Affiliation:	NY Chapter 1 (all counties not listed below) NY Chapter 2 (Brooklyn, Queens, Nassau & Suffolk) NY Chapter 3 (Bronx, Manhattan, Staten Island, Dutchess, Orange, Putnam, Rockland and Westchester) Reach Out & Read Affiliate
Appointment needed?:	Yes No
If yes, who is your Senator and/or Assembly Member for afternoon visits?:
Bus Ride to Albany needed?:	Yes No
If yes, what is your Pickup Location?:	Bus #1: Stony Brook Hospital 4:30am Bus #1: North Shore LIJ (iPark free self parking, 450 Lakeville Road, Lake Success) 5:35am Bus #1: Elmhurst Hospital 6:15am Bus #2: Maimonides Hospital 5:00am Bus #2: NYU Langone Medical Center 5:30am Bus #2: Mt. Sinai Hospital 6:00am Bus #2: Maria Fareri Children’s Hospital at Westchester Medical Center 6:45am