AAP NY Chapter 2: Nutritional Needs of the NICU Graduate - March 4, 2014 - REGISTRATION FORM

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First Name:
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Designation (MD, FAAP, PhD, etc.):
Membership Category: AAP NY Chapter 2 Member ($25 Refundable CHECK – refunded at the program)
AAP NY Chapter 2 Member ($25 Refundable CREDIT CARD Payment – refunded after program is attended)
AAP NY Chapter 3 Member ($25 Refundable CHECK – refunded at the program)
AAP NY Chapter 3 Member ($25 Refundable CREDIT CARD Payment – refunded after program is attended)
Resident ($25 Refundable CHECK – refunded at the program)
Resident ($25 Refundable CREDIT CARD Payment – refunded after program is attended)
Medical Student ($25 Refundable CHECK – refunded at the program)
Medical Student ($25 Refundable CREDIT CARD Payment – refunded after program is attended)
Non-Member Physician ($60 paid by CHECK - nonrefundable)
Non-Member Physician ($60 paid by CREDIT CARD - nonrefundable)
Special Meal Request (if applicable): Vegetarian
Kosher