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Wayne.Atwood
2019-08-27T09:43:28-04:00
2019 Conference Attendees
Registration Type
Attendee
Exhibitor
Student
Missionary
Spouse
Attendee
*
Name of Residency Program
*
Year of Completion
*
Exhibitor
*
Will items be sold/promoted at your booth?
*
Yes
No
Please describe/list items to be promoted and/or sold.
*
Summarizing is acceptable for written materials. For example: 'Books fitting the mission of AMEN published by Pacific Press' or Glad Tidings Publishers would be sufficient for those organizations.
Addons
Electricity for Exhibit Space - Free for regular use
Child Care
Child Care ($10)
Childcare Friday afternoon during the seminars (2-5:30pm)
Registration Deposit Method
*
Credit Card
Check
Your refundable $100 deposit may be made by mailing a check to
AMEN
PO Box 398
Weed, CA 96094-0398
Please write STUDENT ATTENDEE DEPOSIT on the memo line of the check so your check will not be cashed. Checks will be destroyed and PayPal deposits refunded by November 13, 2020 UNLESS you do not show up or if you cancel AFTER October 18, 2020.
Medical/dental school
*
Area of Study
*
Medical Student
Dental Student
Graduation Year
*
Arrival Date
*
Thursday 10/31
Friday 11/1 (by lunch at 1pm)
Friday 11/1 (by supper at 6pm)
Friday 11/1 (later in the evening)
Sabbath 11/2 - ONLY - No hotel
Departure Date
*
Sabbath 11/2
Sunday 11/3
Roommate Type
*
Spouse
Assign
Preferred - list name
Roommate Type
Gender
*
Male
Female
I confirm that my spouse and I are already married
*
Yes
1. Please state your reasons for why you need a subsidy to attend the AMEN conference. Please include your reasons for wanting to attend the conference, your professional background, and plans for how you hope to further the mission of AMEN.
*
2. Please attach a letter of good standing from your church pastor (letter must be on church letterhead)
*
Drop a file here or click to upload
Choose File
Maximum upload size: 268.44MB
3. Please note, we do not pay for airfare to attend the conference. Also, the subsidy granted may only be for a portion of the total conference cost, and not the full amount.
*
I accept the conditions
Total
Discount Code
First Name
*
Last Name
*
Degree
BMed, FACRRM
BSN
DD
DDS
DMD
DNP
DO
DPM
DRPH
LPN
LVN
MD
MDH
MPH
MS
NP
OD
OT
PA
PC
PhD
PHN
PT
RD
RDH
RDN
RN
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Other (enter Country)
State
Select other for international
Cell Phone
*
Email
*
Specialty
Addiction Medicine
Allergy & Immunology
Anesthesiology
Cardiology
Dentistry-General
Dermatology
Emergency Medicine
Endocrinology
Family Practice
Gastroenterology
Geriatrics
Infectious Diseases
Internal Medicine
Lifestyle Medicine
Nephrology
Neurology
OB/GYN
Occupational Medicine
Oncology
Optometry
Oral Surgery
Orthopedic Surgery
Otolaryngology
Pediatrics
Preventative Medicine
Psychiatry
Pulmonary Disease
Radiology
Rheumatology
Sports Medicine
Surgery-General
Urology
Other
Other
Age
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Continuing Education
CME Credits - $45
CDE Credits - $45
Dental License #
OE Tracker #
Organization
*
Mission
*
Goal
*
Is this your first AMEN conference?
*
Yes
No
I am planning on attending the business meeting on Thursday 10/29 at 5:30pm.
*
Yes
No
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