40th Annual Michigan Family Medicine Research Day May 25, 2017 Bird Rate Regular Rate Registration Fees On or before May May 2nd May – (Group Forms & payment must be received by May 19th) 1st 19th Physician $150 $170 Resident/Fellow $100 $120 Practitioner $90 $110 (Physician Assistant, Nurse, Nurse Practitioner) Student $25 $45 (Medical, Nursing) Cancellation policy: Cancellations or refund requests must be received by May 19th; a $25 cancellation processing fee will be assessed to all cancelled registrations. Cancellation or refund requests after May 19th will not be honored. To cancel a registration, please send an email to with the name of the activity and in the subject line. “Cancellation” Directions - Complete the form with all required information and submit by May 19th via one of the following methods registration will not be available on-site): completed form with credit card payment information to -or- Fax completed form with credit card payment information to 248-551-0748 (this is a confidential fax line) Mail completed form with check payment to: Beaumont Hospital, Royal Oak, 3601 W 13 Mile Road, ABW-305, Continuing Medical Education, Attn: Jessica Rice, Royal Oak, MI 48073. NOTE: The email address must be unique to each registrant. All fields in red must be completed. A summary of confirmation numbers and payment receipts can be emailed separately to a single email address if needed. Registration Fee: $ First Name Last Name Degree Affiliation Specialty Physical, Dietary, Beaumont ID other needs (if applicable) Address 1 Address 2 City State Zip Phone Registration Fee: $ Name Last Name Degree Affiliation Specialty Physical, Dietary, Beaumont ID other needs (if applicable) Address 1 Address 2 City State Zip
40th Annual Michigan Family Medicine Research Day May 25, 2017 Registration Fees (Group Forms & payment must be received by May 19th) Bird Rate On or before May 1st Regular Rate May 2nd – May 19th Physician $150 $170 Resident/Fellow $100 $120 Practitioner (Physician Assistant, Nurse, Nurse Practitioner) $90 $110 Student (Medical, Nursing) $25 $45 Cancellation policy: Cancellations or refund requests must be received by May 19th; a $25 cancellation processing fee will be assessed to all cancelled registrations. Cancellation or refund requests after May 19th will not be honored. To cancel a registration, please send an email to with the name of the activity and “Cancellation” in the subject line. Directions - Complete the form with all required information and submit by May 19th via one of the following methods registration will not be available on-site): completed form with credit card payment information to -or- Fax completed form with credit card payment information to 248-551-0748 (this is a confidential fax line) Mail completed form with check payment to: Beaumont Hospital, Royal Oak, 3601 W 13 Mile Road, ABW-305, Continuing Medical Education, Attn: Jessica Rice, Royal Oak, MI 48073. NOTE: The email address must be unique to each registrant. All fields in red must be completed. A summary of confirmation numbers and payment receipts can be emailed separately to a single email address if needed. Registration Fee: $ First Name Last Name Degree Affiliation Specialty Beaumont ID (if applicable) Physical, Dietary, other needs Address 1 Address 2 City State Zip Phone Registration Fee: $ Name Last Name Degree Affiliation Specialty Beaumont ID (if applicable) Physical, Dietary, other needs Address 1 Address 2 City State Zip
Registration%20Form%20-%20Group%20Registrants.docx