Registration for 2008 YPS Interim 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.

*Status
State Delegate
Specialty Society Delegate
Federation Staff
Guest

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

AMA-YPS Handbook
To reduce the use of paper at the 2008 Interim Assembly Meeting, the AMA-YPS will be printing fewer handbooks. 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 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 or credentials), 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
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. This information will be sent closer to the meeting.

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