NAME: __________________________________ DEGREE:________________________

REPRESENTING: __________________________________________________________

Mailing Address for CME Certificate: __________________________________________

_______________________________________________________________________

Telephone: _______________ Fax: ________________ E-mail: ____________________

Specialty/Profession: _____________________________________________________

Last Four Digits of Social Security Number:____________________________________

Please check one:

_____Delegate _____ Alternate ______Associate Member ______Clerkship Coordinator

Is this your first time attending this meeting?

____ Yes ____ No

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REGISTRATION DETAILS:

After March 3, 2008, a late fee of $25 will be assessed to both members and non-members.

(Registration fee covers costs for the Registrant Only for Saturday night dinner, poster reception, two lunches, continental breakfast on Friday and Saturday, breaks, and other costs associated with the meeting. You may purchase additional meal tickets for the group dinner.)

1. I would like to attend one of the Pre-conference workshops on Thursday, April 3, 2008, from 8:00 a.m.- 12:00 p.m. (See workshop descriptions for more information. This requires an additional fee of $50.00.)

_____ Leading the Clerkship in Pediatrics: A Workshop for New Clerkship Directors

_____ Successful Grant Writing for Educational Scholarship and Research

_____ Cultural Competency Skills Development in Pediatrics (held off-site; transportation departs at 7:30 am)

2. Workshops- Please denote your top three (1,2,3) for each session. Remember this is on a first come, first serve basis. Final assignments will be in your check-in package.

Friday, April 4, 2008, 1:45 p.m.- 3:15 p.m.
___A1 ___A2 ___A3 ___A4 ___A5 ___A6 ___A7

Saturday, April 5, 2008, 8:30 a.m. - 10:00 a.m.
___B1 ___B2 ___B3 ___B4 ___B5 ___B6 ___B7

Saturday, April 5, 2008, 10:30 a.m. - 12:00 p.m.
___C1 ___C2 ___C3 ___C4 ___C5 ___C6 ___C7

3. Please indicate if you are attending either of the following general meetings:

______Clerkship Coordinators General Meeting (Thursday, April 3, 1:30 p.m. - 4:30 p.m.)

______ Osteopathic Pediatric Clerkship Directors General Meeting (Thursday, April 3, 1:30 p.m. - 4:30 p.m.)

4. Special Event planned - Please indicate if you plan to attend:

COMSEP Dinner on Saturday, April 5, 2008, at The Carter Center from 7:00 p.m. - 9:30 p.m.

_____ Yes _____ No Extra Guest? _____ ($50.00 charge for guest)

Note: Transportation will be provided and will depart theOmni at 6:30 p.m.

(Please note any dietary restrictions in item 7.)

Name of Guest ____________________

5. If you are a Canadian member, will you be attending the PUPDOC dinner meeting on Wednesday, April 2, 2007, from 6:30 p.m. - 10:00 p.m.?

_____ Yes _____ No (Additional fee of $50.00)

6. Research Abstracts and disclosure forms must be received by February 6, 2008. Send to Drs. Sherilyn Smith and Jan Hanson(see enclosure).

7. In order to accommodate Dietary Restrictions, we must know them in advance. Please indicate any restrictions/allergies you may have. ________________________________

If you are a vegetarian, do you eat fish? _____ Yes _____ No

8. Do you want to sign up for CME credit for this meeting? _____ Yes _____ No (Additional fee of $25.00)

9. Fees: Please note and calculate the following fees. A late fee will be charged to registrants after March 3, 2008.

Registration Fee: Members: $375.00 ______

Pre-Conference Workshop Fee: $50.00 ______

CME Administrative Fee: $25.00 ______

PUPDOC Dinner Fee: $50.00 ______

Guest Meals: $50/ Saturday evening ______

Late Fee (after 3/3/08): $25 ______

TOTAL ENCLOSED: ______

10. PLEASE DO THE FOLLOWING:

Return this registration form and check by March 3, 2008 to:

Fax registrations will also be accepted with a note that payment will follow via mail. Fax number 919-929-9255.

Make checks payable to AMSPDC (and note on check for "COMSEP registration"). We are unable to accept credit card payments. Tax ID number: 16-6098016

***REMINDER: Please make your hotel reservation with the Omni CNN Center as soon as possible in order to ensure a room. The cutoff date for our group is March 12, 2008; however, room availability should not be counted on until then as our room block may be picked up prior to that date. Please make your reservations early. Hotel phone: 1-800-843-6664 group name Council on Medical Student Education in Pediatrics. On -line reservations can be made at the link listed below:

http://www.omnihotels.com/FindAHotel/AtlantaCNNCenter/MeetingFacilities/COMSEP4.aspx

For questions, please call Lisa Elliott at 919.942.1993 or e-mail: lhe@abpeds.org