Remote Presence Clinical Innovations Forum
July 17-19, 2008
Overview
Invited Faculty
• Faculty Registration Form
Forum Agenda
Registration
FACULTY REGISTRATION FORM
Please complete and submit the following information by May 30, 2008
PERSONAL INFORMATION
First Name:
Last Name:
Degree:
Specialty:
CONTACT INFORMATION
Hospital or
Organization
Email:
Organization Address:
City:
State:
Country:
Zip:
Daytime Phone:
Fax:
Alternate Phone:
MAILING ADDRESS IF DIFFERENT FROM ABOVE
Mailing Address:
City:
State:
Country:
Zip:
BIOGRAPHY
Please provide a short biography of yourself (below) to be utilized by the moderator.
You may also email or fax your biography to the Forum Organizer at
forum@intouchhealth.com
or (fax) 805-562-8663.
PRESENTATIONS
Presentations will be posted to the Forum website following the meeting.
May we have your permission to post your presentation?
Yes
No
SPECIAL AUDIO/VISUAL NEEDS
We will provide the facility to project PowerPoint computer presentations. You may bring your own computer or bring your presentation on CD or other type of computer media.
Please enter any special Audio/Visual needs in the text box below.
TRAVEL INFORMATION
The Forum Organizer will contact you regarding hotel and flight arrangements. To get us started, please complete the following:
Anticipated arrival date:
Anticipated departure date:
Preferred hometown airport:
FAMILY INFORMATION
Will your family be accompanying you to Santa Barbara?
Yes
No
If yes, please complete the following:
Spouse Name:
Names and ages of children accompanying you:
Child 1:
Child 2:
Child 3:
Child 4:
Name of other guest accompanying you:
Please describe any special needs required by you, your family or guest (e.g., dietary, access) in the box below. You may also include any other notes regarding the meeting.
Thank you! We look forward to hosting you in Santa Barbara for our
2nd Annual Remote Presence Clinical Innovations Forum.
For questions please contact the Forum Organizer at
forum@intouchhealth.com
or 866.804.8592.
