Please enable JavaScript in your browser to complete this form.Registration – Step 1 of 2Emergency Medicine Leadership Summit 2024 Registration We are looking forward to seeing you! Contact InformationName *FirstLastEmail *Phone *EmploymentPrimary Hospital *Are you the department director? *YesNoName of the department director *Registration Fee (second registration is 50%) *Single Registration – $ 45.00Register with a colleague – $ 75.00Colleague's Name *FirstLastColleague's phone *Colleague's email *Comments or Questions (please add any dietary issues we should be aware of here)NextPaymentTotal$ 0.00Stripe Credit Card *CardName on CardUpdating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.Edit Registration Submit Registration
