18th Annual Chronic Illness and Disability Conference: Transition from Pediatric to Adult-based Care Broadcast Site Registration Thursday, October 5, 2017 8:00 am – 12:15 pm (CST) 1:15 pm – 4:15 pm (CST) Friday, October 6, 2017 8:00 am – 12:15 pm (CST) 1:00 pm – 4:00 pm (CST) Deadline: Monday, September 25, 2017 Instructions Complete the following informaton to register as a broadcast site Return the completed form by the deadline to ensure your Organizaton is registered as a broadcast site This conference will not be archived DSHS/MCHB-Funded Organization or UCEDD Insttuton Name Mailing Address City, State, Zip The broadcasting technical specifications have been reviewed and will be tested on the appropriate testing Yes No date? Our Organization commits to the following: Receiving broadcast both days of the conference Appointng a site coordinator who will be responsible for reportng attendance Name Email Phone Appointng a site technical coordinator who will be responsible for on-site technical issues Name Email Phone Guaranteeing a minimum of individuals in attendance from the Organizaton each day # Attendees (NOTE: If this number changes, please re-send this form via email or fax with the updated estimated number by Thursday, September 28th.) Registraton fee payment of $150.00 (Separate registration and payment is required for each broadcast site Multiple sites per registration will no longer be accepted.) Check (Made payable to: Baylor College of Medicine) Credit Card VISA MasterCard AMEX Discover Card Number Exp Date Name Signature Person completing registration: Name Mailing Address Same as Organizaton address City, State, Zip Email Phone Baylor College of Medicine, One Baylor Plaza, MS: BCM 155, Houston, Texas 77030 | T: 713.798.8237 | E: cme@bcm.edu Rev 07.2017 18th Annual Chronic Illness and Disability Conference: Transition from Pediatric to Adult-based Care Broadcast Site Registration Submit to cme@bcm.edu or via fax to 713.798.7955 Baylor College of Medicine, One Baylor Plaza, MS: BCM 155, Houston, Texas 77030 | T: 713.798.8237 | E: cme@bcm.edu Rev 07.2017 ...18th Annual Chronic Illness and Disability Conference: Transition from Pediatric to Adult-based Care Broadcast Site Registration Submit to cme@bcm.edu or via fax... Medicine, One Baylor Plaza, MS: BCM 155, Houston, Texas 77030 | T: 713.798.8237 | E: cme@bcm.edu Rev 07 .2017