registration form - Kentucky Osteopathic Medical Association

Kentucky Osteopathic Medical Association
2015 Annual Convention
Pre-Medical Conference
Saturday, June 27, 2015 9:00 a.m. – 3:00 p.m.
●
Hyatt Regency Hotel ● Lexington, KY
Goals
• To familiarize pre-medical students and pre-medical advisors with
osteopathic medicine.
• To acquaint pre-medical students and pre-medical advisors with the
admissions requirements, program of study, and student life offered by
University of Pikeville-Kentucky College of Osteopathic Medicine.
• To provide pre-medical students and pre-medical advisors the
opportunity to interact with osteopathic physicians and to hear
presentations on topics related to the practice of osteopathic medicine.
• To receive individual guidance on the application process.
Registration
In order to participate in this Pre-Medical Conference, participants must
register. Early registration is encouraged to reserve a space in this daylong
program as space is limited. The deadline for registration is June 2, 2015.
• Pre-Medical Advisors, Parents and Students - $20 each
• Students receive overnight accommodations at the Hyatt Regency Hotel
for the evening before the event, provided by KOMA. Advisors and
other guests will pay for their own lodging.
• Breakfast and Lunch on the day of the conference is provided for all
registered.
• Professional attire is suggested. Shirt and tie for men and dress
slacks/skirts/dresses for women. No jeans, please.
Osteopathic Medicine
A complete system of medical care with a philosophy that combines the needs of the patient with current practices of
medicine, surgery and obstetrics, and emphasizes the inter-relationships between structure and function, and
appreciation of the body’s ability to heal itself.
Kentucky Osteopathic Medical Association
2015 Annual Convention
Pre-Medical Conference Registration
Saturday, June 27, 2015
9:00 am – 3:00 pm
Hyatt Regency Hotel
Lexington, KY
Please Type or Print Clearly. (One registration form per person.)
Name (as you would like it to appear on your badge):
First:
Nickname:
Last:
Address:
City:
State:
Zip:
Daytime Phone:
Email Address: (required)
❏ Student ($20) at College/University
No cost housing is provided to students courtesy of KOMA for Friday, June 26, 2015 ONLY (Shared Occupancy).
Additional accommodations may be made by contacting the Hyatt Regency Hotel.
Reserve Room:
❏ Yes
❏ No
Roommate Preference (Same Sex):
If no preference, we will be placing you with a same sex roommate for the evening. Your roommate
pairing will be sent to you after June 9.
❏ Advisor ($20) at College/University
❏ Parent ($20) of
Payment:
❏ Check or Money Order (Made payable to KOMA)
❏ Credit card (fill in below)
Credit Card Number:
Exp
Print Name:
Signature:
Registrations must be received by June 2, 2015.
Please mail registration with payment to:
KOMA ● 2424 American Lane ● Madison, WI 53704
Telephone: 608-441-1060 ● Fax: 608-443-2474
Email: info@koma.org