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2021 IFSER Educator's Summit Registration
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Email
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Your email
July 23rd & July 24th Costa Mesa, California
Attendee's First Name
*
Your answer
Attendee's Last Name
*
Your answer
Mailing Street Address
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Your answer
City
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Your answer
State
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Your answer
Zip Code
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Your answer
E-Mail Address (for emailing your CME's)
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Your answer
ARDMS #
Your answer
SDMS #
Your answer
CCI #
Your answer
Phone Number
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Your answer
Date of Birth (for CME's)
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MM
/
DD
/
YYYY
Will you be staying at the hotel chosen by IFSER? The Westin, South Coast Plaza, Cost Mesa, CA.
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Yes
No
Please indicate the days you plan to attend:
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Friday
Friday Night Social
Saturday
Will you be bringing a guest to the Friday Night Social; if so there will be a $20 fee for food and 2 beverages.
Required
Will you be using the PayPal link provided on the 2021 Educator's Summit page at
www.IFSER.org
or mailing a check? Mail Check To: P O Box 132168 Tyler, TX 75713
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PayPal
I plan to pay with check
To assist us in tracking registrations, please indicate the name of the person or organization who will be making the payment for this attendee. (If self, please state "self")
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Your answer
What college or hospital are you from or representing include City and State?
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Your answer
NOTE: Breakfast, Lunch, 2 breaks each day will be provided. Social/Networking with food/beverages will be provided Friday night. For special food allergies, please plan accordingly. Thank you.
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A copy of your responses will be emailed to the address you provided.
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