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Registration Form

Intensive Workshop in Health Care Ethics

Division of Medical Humanities: UAMS College of Medicine

Little Rock, Arkansas

May 2009

Name____________________________________________________________

Organization______________________________________________________

Mailing Address__________________________________________________________

City___________________________________________State_______ZIP_____

Business Telephone_____________________ Fax_________________________

Email_____________________________________________________________

Occupation________________________________________________________

Please make your hotel reservations directly with the Hilton Little Rock Metro Center, (501) 748-4705; toll free in North America 1-800-HILTONS; fax (501) 748- 4758; website www.hilton.com. 

 Notes:

1. The meeting registration fee includes refreshment breaks and lunch.
2. Special dietary requests: ________________________________________

Please mail this form and your check to: Ethics Workshop, Division of Medical Humanities, COM/UAMS, 4301 W. Markham, Slot 646, Little Rock, AR 72205.

We can also take credit card registration by phone

Early Registration is Advised.

Payment Information - Make checks payable to UAMS Foundation Fund.

 A limited number of scholarships are available for those who do not have institutional support. For more details contact:

UAMS Division of Medical Humanities

4301 West Markham, Mail Slot 646

Little Rock, AR 72204

Phone: 501 – 661.7970

Fax: 501 – 661-7967

Email: vanpeltcarola@uams.edu