Pepper Center Annual Meeting Registration2018

2018 ANNUAL MEETING REGISTRATION FORM CLAUDE D PEPPER OLDER AMERICANS INDEPENDENCE CENTERS APRIL 30 – MAY 1, 2018 RENAISSANCE ARLINGTON CAPITAL VIEW REGISTRATION DEADLINE: FRIDAY MARCH 9, 2018 ATTENDEE INFORMATION (Please print or type clearly) FIRST NAME LAST NAME MIDDLE INITIAL TITLE AFFILIATION AT OAIC OAIC/INSTITUTION MAILING ADDRESS CITY/STATE/ZIP PHONE FAX E-MAIL RANK CENTER AFFILIATION  SENIOR FACULTY MEMBER  Pepper OAIC  Alzheimer’s Disease Center  JUNIOR FACULTY MEMBER  HCSRN member  NIH/NIA  JUNIOR FACULTY SCHOLARSHIP AWARDEE*  ROYBAL  Other  Other _  RCMAR If you are completing this form for another person please include your name and phone number: NAME _ PHONE/EMAIL REGISTRATION FEE: $250.00 (please use the following payment options below) To pay by check Make check payable to: Wake Forest University Health Sciences and mail to: Wake Forest University Health Sciences Attn: Abby Archer Section on Geriatrics Medical Center Boulevard Winston-Salem, NC 27157 To pay by Credit Card If paying by credit card, you may Complete online registration form and submit FAX your registration to 336-713-8588 (Attn: Abby Archer) Email PDF version to the Pepper OAIC at peppercenter@wakehealth.edu Card # Exp Date Name on Card Signature / SLEEP ROOM ACCOMMODATIONS Reservation deadline: Monday, April 2, 2018 Two methods to make sleeping room reservations at a rate of $284 you have two options: ONLINE BOOKING LINK located at Pepper National Website TELEPHONE Call the hotel’s Group Housing Coordinator at 1-800-228-9290 Ask for the Claude D Pepper Meeting Room Block at the Renaissance Arlington Capital View when booking *JUNIOR FACULTY SCHOLARSHIP AWARDEE - If you are serving as your OAIC Junior Faculty Scholar Awardee, please note the Coordinating Center will book your hotel sleep room Please designated the nights you will require sleep accommodations: Sunday 4/30/18  Monday 5/1/18 OAIC ANNUAL MEETING EVENTS JUNIOR FACULTY SESSION (MONDAY AFTERNOON) MOCK STUDY SECTION (MONDAY AFTERNOON) MOCK STUDY SECTION – I WILL SERVE AS A SENIOR REVIEWER SENIOR FACULTY ATTENDEES ONLY (MONDAY AFTERNOON) POSTER SESSION (MONDAY LATE AFTERNOON) DINNER (MONDAY EVENING) MATCH UP FOR JUNIOR FACULTY / SENIOR FACULTY (MONDAY PM) JUNIOR FACULTY BREAKOUT AND BREAKFAST (TUESDAY AM)  YES I PLAN TO ATTEND  NO I WILL ATTEND  YES I PLAN TO PARTICIPATE AND SUBMIT A PROPOSAL  YES I PLAN TO ATTEND BUT WILL NOT SUBMIT A PROPOSAL  NO I WILL NOT PARTICIPATE OR ATTEND THE POSTER SESSION  YES I WILL SERVE AS A REVIEWER  NO I WILL NOT SERVE AS A REVIEWER  YES I PLAN TO PARTICIPATE AND PRESENT A POSTER  YES I PLAN TO ATTEND BUT WILL NOT PRESENT A POSTER NO I WILL NOT PARTICIPATE  YES I PLAN TO ATTEND  NO I WILL NOT ATTEND SPECIAL DIETARY NEEDS? _  YES I WILL PARTICIPATE  YES I PLAN TO ATTEND  NO I WILL NOT PARTICIPATE  NO I WILL ATTEND