PEM Fellows Conference Registration March 9-11, 2025 Seattle, Washington

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Please complete the registration below. All registrations must be completed by February 14th, 2025 at 7:00pm EST.

Please make checks payable to University Hospitals in the amount of $475.00 (if you need to pay by some other method besides check, please contact Connie Smith).

Please send checks to:

University Hospitals, Rainbow Babies & Children's Hospital

Attn: Jodi Von Gundy

11100 Euclid Avenue

MAC 6th Floor

Cleveland, OH 44106

*Please indicate the name of the registrant on the check so payment can be matched to registration.

Please refer all questions regarding conference to Connie Smith (cjsmith@texaschildrens.org). Telephone: (832) 498-8313.

Thanks, and we look forward to seeing you in March.

Email Address

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Last Name

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First Name

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Degree

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Hospital/Institution

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Home Street Address

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Home City

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Home State

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Home Zip Code

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Cell Phone Number

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Training Program Name (i.ei., Pediatric Emergency Medicine Fellowship)

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Year of your fellowship?

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First Year

Second Year

Third Year

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Director(s) Name

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Mentor(s) Name

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Title of Your 10-Minute Presentation:
MANDATORY TO RECEIVE ASAP FOR PRESENTATION ASSIGNMENTS!!!

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Dietary Restrictions:

Date of Arrival:

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Date of Departure:

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**Fellow Roommate:

(VERY IMPORTANT!!! If you share a room with a fellow, 2 nights’ hotel costs are paid by us. If you do not share a room or bring your spouse/significant other, you will be required to pay one night’s hotel cost.)

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