Annual Child Maltreatment Symposium Registration 2019 Header Image

Annual Child Maltreatment Symposium Registration 2019

Thursday, November 14, 2019: 7:30 a.m. through 4:30 p.m.

Friday, November 15, 2019: 8 a.m. through 3:30 p.m.

Lurie Children's 11th Floor Conference Center

Your Information

Name*
Profession*
Check all that apply
Are you a Lurie Children’s or Lurie Children’s Partner Hospital staff member, nurse or physician?*
Organization Type*
Continuing Education Credits Sought*
Check all that apply - Note that nurses and other HCPs can receive a "participation" certificate that is similar to the one received by physicians but they are not eligible to receive AMA PRA Category 1 credit. They can take their participation certificate to their respective professional organization and they will determine the eligible number of credits.
Attendance s*
Attendance r*

Second Attendee

2nd Attendee Name*
2nd Attendee Profession*
Check all that apply
Is 2nd Attendee a Lurie Children's staff member, nurse or physician? *
Organization Type of 2nd Attendee*
Continuing Education Credits Sought by 2nd Attendee*
Check all that apply - Note that nurses and other HCPs can receive a "participation" certificate that is similar to the one received by physicians but they are not eligible to receive AMA PRA Category 1 credit. They can take their participation certificate to their respective professional organization and they will determine the eligible number of credits.
Attendance s2*
Attendance r2*

Third Attendee

3rd Attendee Name*
3rd Attendee Profession*
Check all that apply
Is 3rd attendee a Lurie Children's staff member, nurse or physician?*
Organization Type of 3rd Attendee*
Continuing Education Credits Sought by 3rd Attendee*
Check all that apply - Note that nurses and other HCPs can receive a "participation" certificate that is similar to the one received by physicians but they are not eligible to receive AMA PRA Category 1 credit. They can take their participation certificate to their respective professional organization and they will determine the eligible number of credits.
Attendance r3*
Attendance s3*

Fourth Attendee

4th Attendee Name*
4th Attendee Profession*
Check all that apply
Is 4th Attendee a Lurie Children's staff member, nurse or physician?*
Organization Type of 4th Attendee*
Continuing Education Credits Sought by 4th Attendee*
Check all that apply - Note that nurses and other HCPs can receive a "participation" certificate that is similar to the one received by physicians but they are not eligible to receive AMA PRA Category 1 credit. They can take their participation certificate to their respective professional organization and they will determine the eligible number of credits.
Attendance r4*
Attendance s4*

Fifth Attendee

5th Attendee Name*
5th Attendee Profession*
Check all that apply
Is 5th Attendee a Lurie Children's staff member, nurse or physician?*
Organization Type of 5th Attendee*
Continuing Education Credits Sought by 5th Attendee*
Check all that apply - Note that nurses and other HCPs can receive a "participation" certificate that is similar to the one received by physicians but they are not eligible to receive AMA PRA Category 1 credit. They can take their participation certificate to their respective professional organization and they will determine the eligible number of credits.
Attendance r5*
Attendance s5*

Sixth Attendee

6th Attendee Name*
6th Attendee Profession*
Check all that apply
Is 6th Attendee a Lurie Children's staff member, nurse or physician?*
Organization Type of 6th Attendee*
Continuing Education Credits Sought by 6th Attendee*
Check all that apply - Note that nurses and other HCPs can receive a "participation" certificate that is similar to the one received by physicians but they are not eligible to receive AMA PRA Category 1 credit. They can take their participation certificate to their respective professional organization and they will determine the eligible number of credits.
Attendance r6*
Attendance s6*

Seventh Attendee

7th Attendee Name*
7th Attendee Profession*
Check all that apply
Is 7th Attendee a Lurie Children's staff member, nurse or physician?*
Organization Type of 7th Attendee*
Continuing Education Credits Sought by 7th Attendee*
Check all that apply - Note that nurses and other HCPs can receive a "participation" certificate that is similar to the one received by physicians but they are not eligible to receive AMA PRA Category 1 credit. They can take their participation certificate to their respective professional organization and they will determine the eligible number of credits.
Attendance r7*
Attendance s7*

Eighth Attendee

8th Attendee Name*
8th Attendee Profession*
Check all that apply
Is 8th Attendee a Lurie Children's staff member, nurse or physician?*
Organization Type of 8th Attendee*
Continuing Education Credits Sought by 8th Attendee*
Check all that apply - Note that nurses and other HCPs can receive a "participation" certificate that is similar to the one received by physicians but they are not eligible to receive AMA PRA Category 1 credit. They can take their participation certificate to their respective professional organization and they will determine the eligible number of credits.
Attendance r8*
Attendance s8*

Ninth Attendee

9th Attendee*
9th Attendee Profession*
Check all that apply
Is 9th Attendee a Lurie Children's staff member, nurse or physician?*
Organization Type of 9th Attendee*
Continuing Education Credits Sought by 9th Attendee*
Check all that apply - Note that nurses and other HCPs can receive a "participation" certificate that is similar to the one received by physicians but they are not eligible to receive AMA PRA Category 1 credit. They can take their participation certificate to their respective professional organization and they will determine the eligible number of credits.
Attendance r9*
Attendance s9*

Tenth Attendee

10th Attendee Name*
10th Attendee Profession*
Check all that apply
Is 10th Attendee a Lurie Children's staff member, nurse or physician? *
Organization Type of 10th Attendee*
Continuing Education Credits Sought by 10th Attendee*
Check all that apply - Note that nurses and other HCPs can receive a "participation" certificate that is similar to the one received by physicians but they are not eligible to receive AMA PRA Category 1 credit. They can take their participation certificate to their respective professional organization and they will determine the eligible number of credits.
Attendance r10*
Attendance s10*

Payment Information

$
If you have a discount code, please enter it above. Note that discount codes are case sensitive! Please be sure to click on the blue "Apply Discount" link in order to have the discount applied.
Payment Method*

Please note that once you submit this form, we will reserve your spot(s) at the conference, but will not consider your registration to be complete until we receive your payment.  Complete details on submitting payment will be provided in your email confirmation. Thank you.

Powered by Formstack Create your own form ›
Cancel
Confirm