Annual Child Maltreatment Symposium Registration

Child Maltreatment Symposium Registration 2023

Thursday, October 26, 2023

Friday, October 27, 2023

Your Information

Course & Cost Center Info:

Name*

First Name*

Initial (optional)

Last Name*

Email*

Profession*

Physician Attorney Social Worker Nurse Trainee (fellow, resident, medical student, graduate student, etc.)

Check all that apply

Attorney Registration & Disciplinary Commission (“ARDC”) Number*

Are you a Lurie Children’s or Lurie Children’s Partner Hospital staff member, nurse or physician?*

YES NO

Location*

In Person Virtual

Organization Type*

Non-profit Government Other

Organization Name*

Continuing Education Credits Sought*

AMA PRA Category 1 Credit(s)™ (physicians, CME) MCLE (attorneys) CEU (social workers) Nursing Continuing Professional Development Contact Hours Participation Certificate (other healthcare professionals)

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^TM. They can take their participation certificate to their respective professional organization and they will determine the eligible number of credits.

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 Only (Friday)

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 Only (Friday)

I would like to register a second person from my organization

Second Attendee

2nd Attendee Name*

First Name*

Initial (optional)

Last Name*

2nd Attendee Email*

2nd Attendee Profession*

Physician Attorney Social Worker Nurse Trainee (fellow, resident, medical student, graduate student, etc.)

Check all that apply

2nd Attendee Attorney Registration & Disciplinary Commission (“ARDC”) Number*

Is 2nd Attendee a Lurie Children's staff member, nurse or physician? *

YES NO

2nd Attendee Location*

In Person Virtual

Organization Type of 2nd Attendee*

Non-profit Government Other

Organization Name of 2nd Attendee*

Continuing Education Credits Sought by 2nd Attendee*

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 Only (Friday)

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 Only (Friday)

I would like to register a 3rd person from my organization

I would like to register a third person from my organization

Third Attendee

3rd Attendee Name*

First Name*

Initial (optional)

Last Name*

3rd Attendee Email*

3rd Attendee Profession*

Physician Attorney Social Worker Nurse Trainee (fellow, resident, medical student, graduate student, etc.)

Check all that apply

3rd Attendee Attorney Registration & Disciplinary Commission (“ARDC”) Number*

Is 3rd attendee a Lurie Children's staff member, nurse or physician?*

YES NO

3rd Attendee Location*

In Person Virtual

Organization Type of 3rd Attendee*

Non-profit Government Other

Organization Name of 3rd Attendee*

Continuing Education Credits Sought by 3rd Attendee*

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 Only (Friday)

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 Only (Friday)

I would like to register a 4th person from my organization

I would like to register a fourth person from my organization

Fourth Attendee

4th Attendee Name*

First Name*

Initial (optional)

Last Name*

4th Attendee Email*

4th Attendee Profession*

Physician Attorney Social Worker Nurse Trainee (fellow, resident, medical student, graduate student, etc.)

Check all that apply

4th Attendee Attorney Registration & Disciplinary Commission (“ARDC”) Number*

Is 4th Attendee a Lurie Children's staff member, nurse or physician?*

YES NO

4th Attendee Location*

In Person Virtual

Organization Type of 4th Attendee*

Non-profit Government Other

Organization Name 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*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 Only (Friday)

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 Only (Friday)

I would like to register a 5th person from my organization

I would like to register a fifth person from my organization

Fifth Attendee

5th Attendee Name*

First Name*

Initial (optional)

Last Name*

5th Attendee Email*

5th Attendee Profession*

Physician Attorney Social Worker Nurse Trainee (fellow, resident, medical student, graduate student, etc.)

Check all that apply

5th Attendee Attorney Registration & Disciplinary Commission (“ARDC”) Number*

Is 5th Attendee a Lurie Children's staff member, nurse or physician?*

YES NO

5th Attendee Location*

In Person Virtual

Organization Type of 5th Attendee*

Non-profit Government Other

Organization Name of 5th Attendee*

Continuing Education Credits Sought by 5th Attendee*

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 only (Friday)

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 Only (Friday)

I would like to register a 6th person from my organization

I would like to register a sixth person from my organization

Sixth Attendee

6th Attendee Name*

First Name*

Initial (optional)

Last Name*

6th Attendee Email*

6th Attendee Profession*

Physician Attorney Social Worker Nurse Trainee (fellow, resident, medical student, graduate student, etc.)

Check all that apply

6th Attendee Attorney Registration & Disciplinary Commission (“ARDC”) Number*

Is 6th Attendee a Lurie Children's staff member, nurse or physician?*

YES NO

6th Attendee Location*

In Person Virtual

Organization Type of 6th Attendee*

Non-profit Government Other

Organization Name of 6th Attendee*

Continuing Education Credits Sought by 6th Attendee*

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 Only (Friday)

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 only (Friday)

I would like to register a 7th person from my organization

I would like to register a seventh person from my organization

Seventh Attendee

7th Attendee Name*

First Name*

Initial (optional)

Last Name*

7th Attendee Email*

7th Attendee Profession*

Physician Attorney Social Worker Nurse Trainee (fellow, resident, medical student, graduate student, etc.)

Check all that apply

7th Attendee Attorney Registration & Disciplinary Commission (“ARDC”) Number*

Is 7th Attendee a Lurie Children's staff member, nurse or physician?*

YES NO

7th Attendee Location*

In Person Virtual

Organization Type of 7th Attendee*

Non-profit Government Other

Organization Name of 7th Attendee*

Continuing Education Credits Sought by 7th Attendee*

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 only (Friday)

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 Only (Friday)

I would like to register an 8th person from my organization

I would like to register an eighth person from my organization

Eighth Attendee

8th Attendee Name*

First Name*

Initial (optional)

Last Name*

8th Attendee Email*

8th Attendee Profession*

Physician Attorney Social Worker Nurse Trainee (fellow, resident, medical student, graduate student, etc.)

Check all that apply

8th Attendee Attorney Registration & Disciplinary Commission (“ARDC”) Number*

Is 8th Attendee a Lurie Children's staff member, nurse or physician?*

YES NO

8th Attendee Location*

In Person Virtual

Organization Type of 8th Attendee*

Non-profit Government Other

Organization Name of 8th Attendee*

Continuing Education Credits Sought by 8th Attendee*

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 Only (Friday)

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 Only (Friday)

I would like to register a 9th person from my organization

I would like to register a ninth person from my organization

Ninth Attendee

9th Attendee*

First Name*

Initial (optional)

Last Name*

9th Attendee Email*

9th Attendee Profession*

Physician Attorney Social Worker Nurse Trainee (fellow, resident, medical student, graduate student, etc.)

Check all that apply

9th Attendee Attorney Registration & Disciplinary Commission (“ARDC”) Number*

Is 9th Attendee a Lurie Children's staff member, nurse or physician?*

YES NO

9th Attendee Location*

In Person Virtual

Organization Type of 9th Attendee*

Non-profit Government Other

Organization Name of 9th Attendee*

Continuing Education Credits Sought by 9th Attendee*

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 Only (Friday)

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 Only (Friday)

I would like to register a 10th person from my organization

I would like to register a tenth person from my organization

Tenth Attendee

10th Attendee Name*

First Name*

Initial (optional)

Last Name*

10th Attendee Email*

10th Attendee Profession*

Physician Attorney Social Worker Nurse Trainee (fellow, resident, medical student, graduate student, etc.)

Check all that apply

10th Attendee Attorney Registration & Disciplinary Commission (“ARDC”) Number*

Is 10th Attendee a Lurie Children's staff member, nurse or physician? *

YES NO

10th Attendee Location*

In Person Virtual

Organization Type of 10th Attendee*

Non-profit Government Other

Organization Name of 10th Attendee*

Continuing Education Credits Sought by 10th Attendee*

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 only (Friday)

Attendance*

Both Days (Thursday - Friday) Day 1 Only (Thursday) Day 2 Only (Friday)

Payment Information

Total Fee $

Discount Code

Administrative Use only.

Payment Method*

Credit Card Check

Name as it appears on credit card*

Credit Card*

Please make out your check to Ann & Robert H. Lurie Children's Hospital of Chicago and send to:

Ann & Robert H. Lurie Children's Hospital of Chicago
Child Abuse Pediatrics - Attn: Kelly Smith
225 East Chicago Avenue, Box 16
Chicago, IL 60611

Please send your check in time to reach us on or before October 13, 2023. Note that while we will reserve your spots for the symposium, your registration will not be considered complete until we receive your payment.

These details on submitting payment will be provided in your email confirmation as well. Thank you.