ONLINE REGISTRATION FORM

REGISTRATION DEADLINE: FRIDAY, MARCH 26, 2010

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 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 9.

HOTEL INFORMATION (GEORGETOWN UNIVERSITY CONFERENCE CENTER)

Please note: If you register for the Annual Scientific Meeting and are unable to attend, you must notify the Foundation by March 26th 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

Additional Comments/Requests:

MENTORING SESSION (FOR ALUMNI ONLY)

SARNOFF CARDIOVASCULAR RESEARCH FOUNDATION
SCIENTIFIC COMMITTEE AND BOARD OF DIRECTORS
ALUMNI MENTORING SESSION 2010

Please plan to participate in the Alumni Mentoring Session on Friday, April 30, 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 with links to their biographies are below to assist you in deciding with whom you wish to meet.

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