ECU Brody School of Medicine Academic and Faculty Development: Workshop Registration Form

WORKSHOP REGISTRATION FORM

Please complete and submit the form below to register for a workshop offered by the Office of Academic and Faculty Development. Once you click Submit, you will receive an e-mail from us to confirm your participation.

Workshop Name:
Workshop Date:

Meal:
	This workshop includes a pre-session boxed meal with registration (at no cost to you). Please specify whether or not you would like to join us for the meal prior to this workshop session so that we might provide an accurate count for the catering order.
Dietary Needs:
	If you would like a boxed meal, please specify if you prefer a vegetarian entree or if you have any other special dietary needs.
First Name:
Last Name:

Gender:
	Provision of this information is voluntary. It will be used for non-discriminatory purposes such as determining how we might effectively meet the diverse needs of faculty.
SSN Last 4:
	You must provide the last four digits of your Social Security Number in order to obtain CME credits.
Degree:
Specify Other:
	Please specify your degree if not found on the selection list above.
Academic Rank:
Specify Other:
	Please specify your academic rank if not found on the selection list above.
ECU Health Sciences Affiliation:
Specify Other:
	Please specify your affiliation if not found on the selection list above.
Department:
Specify Other:
	Please specify your department if not found on the selection list above.
Office Address:

E-mail:

Daytime Phone:

Comments: