VA Gen Assembly Day Registration

PEDIATRIC GENERAL ASSEMBLY DAY
Registration Form
Thursday, January 28, 2010

Early Registration Deadline December 18, 2009

First Name*

Last Name*

Program*

Phone*

Email Address*

Street Address

City*

State*

Zip Code*

Please check:

Other; please specify

Are there specific child health issues that you are interested in working on this legislative session?

Have you ever met with your state or federal legislators before?

Yes No

University of Virginia Health System