EM Summit Registration

Maine Emergency Medicine Leadership Summit

April 4, 2024   |   Hilton Garden Inn, Freeport, Maine

2024 Summit Brochure | Speaker Biographies (coming soon)

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Name *

First

Last

Email *

Phone *

Primary Hospital *

Are you the department director? *

• Yes
• No

Name of the department director

Credentials (check all that apply *

• MD
• DO
• FACEP
• PA-C
• MPH
• MBA
• RN
• Other

Other, please add credentials here.

Registration

Registration Type *

• In person
• Remotely
• I am unable to attend this year

Registration (check one) *

• In Person (Single Registration) – $45.00
• In Person (bring a colleague and save!) – $65.00

Virtual Registration *

• Virtual Registration – $20.00

Colleague's Name *

First

Last

Colleague Credentials (check all that apply) *

• MD
• DO
• FACEP
• PA-C
• MPH
• MBA
• RN
• Other

Other credentials (colleague)

Colleague's phone *

Colleague's email *

Registration includes a continental breakfast, lunch and break snacks. Let us know if you have any dietary restrictions or allergies. We will do our best to accommodate dietary needs we are alerted to in advance of the meeting.

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Registration Summary and Payment

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Registration Total

$0.00

Payment Type *

• Pay by Credit Card
• Pay by Check

Credit Card Payment *

Card

Name on Card

If paying by check, make checks payable and mail to:

Maine Chapter ACEP, PO Box 190, Manchester, ME 04351

Tax ID #:  23-7147403

We appreciate your RSVP for the 2024 Emergency Medicine Leadership Summit. We hope to see you next year!

Maine Chapter ACEP

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