Fourth Annual Women’s Health Symposium
July 30 - August 1, 2010 • Tan-Tar-A Resort, Lake Ozark, Missouri
som.missouri.edu/CME
Sponsored by
Department of Obstetrics, Gynecology
and Women’s Health
Office of Continuing Education
MU Sinclair School of Nursing
som.missouri.edu/CME
Registration Form
City State Zip County
Name _____________________________________________________________
Degree ___________________________
___ First time conference registrant
___ I DO NOT want my name on the conference roster
Hospital Affiliation ______________________________________________________
Department ____________________________________________________________
Office Address ___________________________________________________________
________________________________________________________________________
Office Phone _____________________ Office FAX Number ____________________
E-mail Address__________________________________________________________
Please charge my: ___ Discover ___ Mastercard ___ Visa Exp. Date __________
Account Number ______________________________________________________
Signature ____________________________________________________________
Address if different from above ___________________________________________
_____________________________________________________________________
___ Check enclosed (Make payable to the University of Missouri)
The University of Missouri School of Medicine fully intends to comply with the
legal requirements of the ADA. Please specify if any accommodation or special
arrangements are required to attend this conference, including any dietary
restrictions you have and we will try to accommodate your request(s).
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Mail Completed Application and Payment to:
Women’s Health Symposium
Office of Continuing Medical Education
c/o Shirley Walters
2401 Lemone Industrial Blvd., DC345.00
Columbia, MO 65212
You may also register by Faxing your registration form to [573] 882-5666.
Registration may also be completed online: som.missouri.edu/CME
GENERAL INFORMATION
TUITION FEES*: Received on or before July 1, 2010
Practicing Physician $395
Resident, Nurse or Other Provider: $275
Received after July 1, 2010
All Practitioners $500
Obstetric Emergencies Course $500
CANCELLATION/REFUND/SUBSTITUTION POLICY:
A full refund of fees, less $50 administrative fee, will be made if cancellation is received in writing on or before Friday, July
16, 2010. After July 16, and until July 26, 2010, the administrative fee will increase to $100. No refunds will be made after
July 26, 2010.
HOW TO REGISTER: 1. Online (som.missouri.edu/CME) using our secure server and a credit card.
2. Download a pdf file and mail it to: 4th Annual Women’s Health Symposium
University of Missouri
2401 Lemone Industrial Blvd., DC345.00
Columbia, MO 65212
3. Download a pdf file and fax to [573] 882-5666
4. Complete registration form below and mail or fax to same address or fax number listed above.
