2008 Symposium Registration

All fields marked with an asterisk * are required

TO REGISTER: Fill in the following form. Cost for the Symposium is $135. You may pay by check or PayPal . You will receive a confirmation email of your registration. If you have any questions about the conference, please contact: Sorelle Davis at 770-928-2276 ext. 163 or email at Sorelle.Davis@acrm.com

1. Contact Information

*First Name:
*Last Name:
Degree(s)/Credentials:
*Name on Badge:
Practice/Institution:
Position in Practice/Institution:
*Address:
Address2:
Address3:
*City:
*State:
*Zip:
*Phone:
Extension:
*Email Address:
Special Accomodations:
(dietary, handicap, etc.)



2. Roundtable Discussion Signup

Please select up to 3 Roundtables in which to participate. Please indicate your preference of Roundtables ranking your three choices from 1 - 3 with 1 being first and 3 being last. Every effort will be made to respect your order of preference, but assignments will be made on a first come, first served basis.
Having a baby, how old is too old?
Surgical Complications
First Trimester Screening
Male Factor Infertility: When to Involve a Urologist
Infertility Nursing
Emotional Aspects of Infertility
From Paper to Mouse: Converting to Electronic Medical Records



3. Payment Information

*Payment Type:
Select one		    Mailed Check

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