SARNOFF CARDIOVASCULAR RESEARCH FOUNDATION
31ST ANNUAL SCIENTIFIC MEETING
April 28-30, 2011
Gaylord National Harbor Hotel, National Harbor, Maryland

ONLINE REGISTRATION FORM

REGISTRATION DEADLINE: FRIDAY, MARCH 25, 2011

REGISTRANT CONTACT INFORMATION

FIRST NAME:   LAST NAME:

Name you wish to appear on nametag:

DEGREE(S): Select MD PhD MD/PhD
CURRENT TITLE:
INSTITUTIONAL AFFLIATION/EMPLOYER:

MAILING ADDRESS:

EMAIL ADDRESS:

PHONE:

SPOUSE/GUEST: yes no

If applicable, please print name of Guest:

Additional costs:

Hotel room - $100 per room/per night Dinner guest fees - $75/per night, if attending

Guest fees may be paid using Paypal or a check made out to the “Sarnoff Cardiovascular Research Foundation” may be sent to the Sarnoff Foundation Office, 731 Walker Road, Suite G2, Great Falls, VA 22066.

Guest Cancellation Policy - You will be responsible for all guest fee(s) if you do not cancel the reservations (hotel and/or event(s)) with the Foundation by April 1.

HOTEL INFORMATION (GAYLORD NATIONAL HOTEL)

Please note: If you register for the Annual Scientific Meeting and are unable to attend, you must notify the Foundation by March 25th to cancel your hotel reservation. If you notify the Foundation after this date, you will need to pay a $50/night hotel reservation penalty.

MEETING/EVENT REGISTRATION

PERMISSION TO PUBLISH

From time to time, the Sarnoff Foundation may reproduce photographs, or other media forms, of the event attendees for its official publications. Additionally, there may be occasions where the Foundation wishes to utilize certain information about the attendees including name, address, school and laboratory affiliations, and other appropriate information in the public domain or provided to the Foundation. You agree to allow the Foundation to publish, in any form, and in its discretion, the information contained in such documents or similar documents, as well as any pictures, videos or similar reproductions and recordings made in connection with the Foundation's sponsored events and programs.

Yes, I give permission       No, I decline permission

Additional Comments/Requests:

MENTORING SESSION (FOR ALUMNI ONLY)

SARNOFF CARDIOVASCULAR RESEARCH FOUNDATION
SCIENTIFIC COMMITTEE AND BOARD OF DIRECTORS
ALUMNI MENTORING SESSION 2011

Please plan to participate in the Alumni Mentoring Session on Friday, April 29, from 7:30 - 8:30 a.m. This session will give Sarnoff Alumni the opportunity to meet with one or more senior members of the Scientific Committee and/or Board of Directors, one-on-one, to discuss your career planning.

Preregistration is required. A list of participating Scientific Committee and Board members is listed below. You may select your top two faculty choices.

You may only select one Mentor for each session! (Example: Checking the box for Session 2 on one mentor will remove the check from Session 2 on a previously selected mentor.)

Session 1 – 7:30-8:00 am
Session 2 – 8:00-8:30 am