Registration for 2008 YPS Annual Assembly Meeting

Personal Information

*Asterisk indicates required field.

Medical Education Number (your ME # is printed on your JAMA and AMNews mailing labels and your AMA membership card)

*First Name

Middle

*Last

Suffix (Jr., III, etc.)

Degree (MD, DO, MPH, etc.)

*Address1

Address2

*City

State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pacific Islands ** Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington Washington, D.C. West Virgina Wisconsin Wyoming

*ZIP

*Phone

Fax

*E-mail

Your e-mail address will not be shared, sold, traded, exchanged or rented. See our Privacy Policy for more information.

*Society Represented (Specify name of Military branch, state medical society or specialty society)

*Status
Delegate
Alternate Delegate
Federation Staff
Guest

AMA-YPS Handbook
Please let us know how you prefer to receive your AMA-YPS Assembly meeting materials (check all that apply):
I will download from the AMA-YPS Web site (AMA-YPS will e-mail you regarding availability);
Please send me a CD-ROM in advance;
I would like a CD-ROM at the meeting rather than in advance; and/or
I will need a print Handbook at the meeting.


AMA-YPS Volunteer Opportunities
Your Governing Council encourages you to get involved in the Assembly meeting. If you would like to serve on a convention committee (reference, handbook review, credentials or parliamentary procedure), please contact Jane Ascroft. 

This is my first AMA-YPS Meeting.
This is my last AMA-YPS Meeting.

Are you staying for any part of the AMA House of Delegates meeting (check all that apply):
Saturday caucuses convened by states and/or specialties;
Saturday opening HOD session;
Sunday reference committees;
Monday educational sessions, caucuses, or
Tuesday AMA-HOD.

As an AMA-YPS Assembly member, we will be counting on you to report to your society's AMA-HOD delegation. Most states and specialty societies will caucus on Saturday. Would you like AMA-YPS assistance in identifying opportunities for your participation in AMA-HOD caucuses convened by state, specialty or region?
Yes
No

Please print a copy of this form for your records prior to submitting. When you submit this form electronically, you should receive an automatic confirmation that includes a form that we ask you to fill out and bring to the meeting so you can be contacted in case of an emergency. You also should receive an e-mail from the AMA-YPS acknowledging receipt. If you do not receive either of these confirmations, we have not received your registration and it should be resubmitted.

You may contact the Young Physicians Section via e-mail at yps@ama-assn.org if you need additional information or have questions. If you prefer to print this form and return it by fax, you may fax it to (312) 464-5845; Attn: YPS