TALK Learning Session Registration

Please complete the form below to register for the Thursday, August 4, 2016 in-person learning session at the Ohio AAP Offices at 94-A Northwoods Boulevard in Columbus. The session will take place from 12:00-5:30pm.

Name of Practice/Organization *

Email Address of Individual Completing Registration Form *

Learning Session Attendee #1

First Name

LS Attendee #1 Last

Last Name, Credentials

Learning Session Attendee #2

First Name

LS Attendee #2 Last

Last Name, Credentials

Learning Session Attendee #3

First Name

LS Attendee #3 Last

Last Name, Credentials

Learning Session Attendee #4

First Name

LS Attendee #4 Last

Last Name, Credentials

Food Allergies

Please indicate if any individuals have special dietary restrictions/food allergies. If yes, use the space to indicate the individual and their restriction.

Number of Exam Rooms

If you are human, leave this field blank.