Registration Form
Please submit by September 23, 2010
First Name
Last Name
Degree
(DO, MD, PhD, RN, etc.)
Title
Organization
Address
Address 2
City
State
Zip Code
Phone
E-Mail
Badge First Name
This is my first time attending a GPIN meeting.
Yes
No
Wednesday, October 13th - Welcome Lunch; 12:00 - 1:00 pm
Yes, I plan to attend
No, I will not attend
Wednesday, October 13th - Reception; 5:30 - 7:30 pm
Yes, I plan to attend
No, I will not attend
Yes, I plan to attend With my significant other
Thursday, October 14th - Reception/Dinner @ Spiaggia, 6:15 - 9:00 pm
Yes, I plan to attend
No, I will not attend
Yes, I plan to attend With my significant other
Friday, October 15th - Lunch; 12:00 noon - 1:00 pm
(Following conference adjournment)
Yes, I plan to attend
No, I will not attend
Yes, I plan to attend With my significant other
1 Ford Place, Detroit, Michigan 48202
Phone: (313) 874-GPIN (4746) Fax: (313) 874-4389
Copyright 2000 Group Practice Improvement Network
