AAP Vaccine Summit - Nov. 15 - 17, 2013 at The Thayer Hotel in West Point, NY - Registration Request Form

Fill out the following information (bold fields are mandatory) and click 'Submit'.

First Name:
Last Name:
Company:
Address 1:
Address 2:
City:
State/Province:
Zip Code:
Email Address:
Verify Email:
Business Phone:
Title (MD, FAAP, PhD, etc.):
AAP Chapter (Registration Fees include 2 nights at hotel & 6 meals):	NY Chapter 1 Member: $100 (all counties not listed below) NY Chapter 2 Member: $100 (Brooklyn, Queens, Nassau, Suffolk) NY Chapter 3 Member: $100 (Bronx, Manhattan, Staten Island, Dutchess, Orange, Putnam, Rockland, and Westchester Counties)
Guest 1 - Full Name:
Guest 1 - Age:	Adults (13 & over): $230 Children 6 - 12: $140 Children 5 & under: No charge
Guest 2 - Full Name:
Guest 2 - Age:	Adults (13 & over): $230 Children 6 - 12: $140 Children 5 & under: No charge
Guest 3 - Full Name:
Guest 3 - Age:	Adults (13 & over): $230 Children 6 - 12: $140 Children 5 & under: No charge
Guest 4 - Full Name:
Guest 4 - Age:	Adults (13 & over): $230 Children 6 - 12: $140 Children 5 & under: No charge