Pacific Aids Education & Training CenterBay Area and North Coast AIDS Education and Training CenterBay Area and North Coast AIDS Education and Training Center Logo

Event Title: IAS 2017 Report Back (Community Consortium)
Date: 30-Aug-17



We collect the following information solely for the purpose of facilitating the on-line registration process for our events. This information is not stored with or connected to your unique PIF ID.
 
Email:    * required
Confirm Email:    * required
 
Save Info:    (Save your contact information to ease future registrations.)
First Name:    * required
Last Name:    * required
Degree:  
Title:    * required
Organization:  * required
Address:  * required
City:  * required
State:  * required
Zip Code:  * required format(xxxxx-xxxx)
Phone:  * required format(xxx-xxx-xxxx)
Phone 2:   format(xxx-xxx-xxxx)
Discipline:  
 Physician
 Physician Assistant
 Nurse
 Nurse Midwife
 Pharmacist
 Social Worker
 Case Manager
 Mental Health Provider
 Substance Abuse Professional
 Health/HIV Educator
 Grants Manager
 Project Manager
 Non Health Discipline
 Other

 Dentist
 Other Dental Professional
 Nurse Practitioner
 Advanced Practice Nurse
Do you want to receive CME/CEUs?     Yes     No

If you are receiving CME/CEUs, what type of CME/CEUs would you like to receive ?   
 Nursing     Medical     LCSW/LMFT*License Number 
Which meal do you prefer?    Regular     Vegetarian  None. I will not be eating onsite.