WWAMI GME Summit

Dates: Sunday, October 9th through Tuesday, October 11, 2022
Registration Fee: $225

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Registration Information

First Name

Last Name

Name Preference for Name Tag

Title

Organization

Home State

Other State

Which program are you affiliated with?

Other - Please Describe

Are you a Medical Resident?

Yes No

Are you a speaker for the WWAMI GME Summit?

Yes No

Which of the following meetings will you be attending?

WWAMI GME Summit (Monday – Tuesday)

Yes No

MT WWAMI 50th Anniversary Reception and Dinner (Sunday Evening)

Yes No

MT WWAMI 50th Anniversary Reception and Dinner
(Sunday Evening) *ONLY* (I will not be attending the GME summit,
but will be attending the WWAMI 50th Anniversary Reception and Dinner)

Yes No

Meals

Please enter the total number of people (including the registrant and any guests) who will be attending the MT WWAMI 50th Anniversary Dinner (Attendees who are not participating in the GME Summit will be charged $25 per person for dinner)

Number of attendees

Names of guests attending

Dietary Restrictions

Contact Information of Registrant

Address 1

Address 2

City

State

Zip / Postal Code

Phone Number

Email Address

Alternate Email Address

Payment

Conference Registration per Attendee is: $225
*Registration fee is waived for Speakers

Total Registration: $

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WWAMI GME Summit

Which of the following meetings will you be attending?

Meals

Total Registration: $

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