Enrollment is limited, so please register early.

  
________________________________________________________
Name: First / Middle / Last  
 

____________________________________
Institutional Affiliation  

  
____________________________________
Home Address  

  
____________________________________
City / State / Zip  

  
(_____)___________(_____)____________
Daytime Phone                            Fax  

  
____________________________________
*Social Security Number  
 

Conference Rate: (please check applicable fee category) 

o Resident $675
(late fee $725 applies as of July 1, 2007) 
(A letter from Residency Program Director MUST be submitted.) 
  
o Physician in Practice, Fellow $775
(late fee $825 applies as of July 1, 2007) 

o Check enclosed payable to: 
        The Regents of the University of California  

o Charge:  o MasterCard   o Visa   o Discover 

#________-_________-_________-_________
 

_____________________________/_________
Authorizing Signature                                    Exp. Date (Mo./Yr.)  
 

Mail to: 

Office of Continuing Medical Education, Pediatrics 
UCLA School of Medicine 
10920 Wilshire Blvd., Suite 1060 
Los Angeles, California 90024-6512 

Or FAX with credit card information and authorizing signature to: (310) 794-2624. 
Written confirmation will be mailed or faxed. 
  

*By Regental authority, your Security Number is requested in order to verify your identity for accurate record keeping. Providing the number is voluntary.  

DISCLOSURE STATEMENT

The FDA has issued a concept paper which classifies commercial support of scientific and educational programs as promotional unless it can be affirmed that the program is "truly independent" and free of commercial influence. In addition to independence, the FDA requires that non-promotional, commercially supported education be objective, balanced, and scientifically rigorous. The policy further states that all potential conflicts of interest of the CME staff and faculty be fully disclosed to the program's participants. In addition, policy of the Accreditation Council for Continuing Medical Education now mandates that the provider adequately manages all identified potential conflicts of interest prior to the program. We, at UCLA fully endorse the letter and spirit of these concepts.

In accordance with applicable Federal laws and University policy, the University of California does not discriminate in any of its policies, procedures, or practices on the basis of race, color, national origin, sex, sexual orientation, age, or disability. Inquiries regarding the University's equal opportunity policies may be directed to Campus Counsel, 3149 Murphy Hall, UCLA, or the Director of the Office for Civil Rights, Department of Education. For information on services for people with disabilities or questions about accessibility, please call (310) 825-1507 (voice or TDD).