Infant Abusive Head Injuries

Second International Pediatric Abusive Head Trauma:
Medical, Forensic, & Scientific Advances & Prevention Programs
Snow King Resort & Conference Center • Jackson Hole, Wyoming
June 25-26, 2009 (optional reception: June 24, 2009)

Register online, by fax, or by mail. If you do not receive a confirmation from Penn State within two weeks, call 717-531-6483 to confirm. Walk-ins and late registrations are accepted only if space is available. Please provide both work and home phone numbers so we can contact you should last-minute changes occur.

Name

PhD

Other

How would you like to have your name printed on your nametag?

Home Address

City

State

Zip Code

Work Phone

Home Phone

Fax Number

Date of Birth (mm/dd/yy)

Specialty/Position

Hospital or Organization

Street Address (HMC/COM employees-provide dept. name/mail code)

City

State

Zip Code

E-mail Address

Special Needs (dietary, access, etc.)

For registrations received on or before May 24, 2009, the early bird fees are:

Both conference days:

Physicians and PhDs

$375

Others

$200

Thursday, June 25, only:

Physicians and PhDs

$200

Others

$125

Friday, June 26, only:

Physicians and PhDs

$200

Others

$125

After May 24, 2009, the fees are:

Both conference days:

Physicians and PhDs

$425

Others

$250

Thursday, June 25, only:

Physicians and PhDs

$225

Others

$150

Friday, June 26, only:

Physicians and PhDs

$225

Others

$150

I will attend the following optional breakfast seminars:
Thursday Friday None

Do you plan to attend the optional reception on Wednesday, June 24?
(included in conference fee) YES NO

5-9 p.m. Take the 20-minute scenic chair lift ride to the top of Snow King Mountain. Take photos, absorb the peaceful atmosphere, and enjoy a cash bar. A western BBQ Buffet will be open from 6:30 - 8:30 p.m. All attendees must depart by 9 p.m. due to darkness/safety concerns. For more information about the reception, which showcases regional cuisine and the stunning backdrop of the Rocky Mountains, please click here.

Number of guest tickets to reception:
adult guest(s) at $65 each
guest(s) age 12 and under at $40 each

Payment method for guest dinners:
Same method as payment for conference (skip to conference payment portion below)
Check payable to Penn State (mail to Registrar, Penn State Continuing Education, G220, PO Box 851, Hershey, PA 17033-0851. Please include a note stating your name and the explanation "payment for guest dinners at Abusive Head Trauma conference.")
Credit card to be submitted via: fax mail phone

Paying by credit card:
Submit your registration information online and call (717) 531-6483 to complete your credit card payment. You may also download the credit card payment form and mail or fax to:

Department of Continuing Education, G220
Penn State College of Medicine
P.O. Box 851
Hershey, PA 17033-0851
Fax: (717) 531-5604

Indicate method of payment for conference:

Check payable to Penn State (mail to Registrar, Penn State Continuing Education, G220, PO Box 851, Hershey, PA 17033-0851 with a note stating that your registration was submitted online. Be sure to include your name if it is not printed on your check)

Bill a sponsoring organization. Fax a letter of authorization from supervisor on company letterhead to 717-531-5604. Include your name and a note stating that your registration was submitted online.

Credit card to be submitted via: fax mail phone

Paying by credit card:
Submit your registration information online and call (717) 531-6483 to complete your credit card payment. You may also download the credit card payment form and mail or fax to:

Department of Continuing Education, G220
Penn State College of Medicine
P.O. Box 851
Hershey, PA 17033-0851
Fax: (717) 531-5604

Fee for HMC/COM employees is the same as above. Payment options:

IDCC sent. IBIS # Send to department ID &HCE.
IDT has been faxed to 717-531-5604 (HMC only).
Memo to bill dept. has been faxed to 717-531-5604 (HMC only). Include budget # and authorized signature