Faculty Information Form - Children and Arthritis, Inc.

Thank you participating as a member of the Conference Faculty. Please provide your information as you would like it printed. Thank you. Questions: edeal@wkhs.com

You will be contacted directly by the LA Chapter of the American Academy of Pediatrics regarding your presentation, learning objectives and CV for continuing education purposes.

Faculty Information Form - Cassidy Conference 2020

Full Name with Post-Nominal Letters exactly as you would like it printed*
Brief Bio (optional)
Title(s)
Office/Hospital/Affiliation*
Address Line 1*
Address Line 2
Address Line 3
City*
State*
Country
Zip Code*
Office Phone Number
Cell Phone Number*
Email Address*
Enter Email Confirm Email
Email Address 2 (optional)
Enter Email Confirm Email
Please enter the title of your presentation exactly as you would like it printed.*
Dietary restrictions or other special requests
Camp Jambalaya Jubilee participation following the conference
Do you intend to bring a Fellow(s) to present at the Poster Session? Fellows should register to attend the conference at childrenandarthrits.org.
Preferred method to contact you regarding the Cassidy Conference - select as many as apply.
- Email
- Office phone
- Cell phone
- Contact staff/assistant
If you wish us to contact a staff/assistant, please provide name, email address and phone number. Thank you.