*First Name:

*Last Name:

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Phone:

Fax:

*Address:

*City:

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*Email:

Affiliation:

Panelist:

I've been asked to participate as a Panelist.

*Small Group Breakout Session:

A. Pediatric Musculoskeletal Disease
B. Pediatric Cardiovascular Disease
C. Pediatric Abdominal and GI diseases
D. Pediatric Neurologic Disorders
E. Pediatric Genitourinary Diseases
F. Pediatric Speech and Audiologic Disorders

*Presentations:

I wish to make a presentation (Upon completion, you will be prompted to register your presentation)
I do NOT wish to make a presentation

*Comment:

I wish to make a comment
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Are you Submitting an abstract? No Yes

Conflict of Interest:

Please list any issue that may give an appearance of conflicts of interest you may have including: affiliations with industry; receipt of grants for research or laboratory equipment from device manufacturers; medical device industry royalties or patents, consultations or board affiliations with medical device firms, etc. It is not necessary to provide details of these conflicts, however, please be sure to include a disclaimer regarding any potential conflicts in your presentation, In order to give a presentation you must provide an written copy of your presentation with an abstract of no more than 250 words as instructed at http://ppleventreg.com/pediatric-clinical-trials/Abstract The deadline for submitting abstracts is going to be Thursday, October 1, 2009.

I do not have any conflicts of interest

Special Accommodations

Please list any special accommodations required while at the workshop such as wheelchair assessability or other disabilities including
hearing impaired requiring an interpreter.

Participant Registration Information

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Registration Form

Conflict of Interest:

Special Accommodations