The 2nd Annual National Health Disparities Elimination Summit Registration


THE CONNECTICUT LEGISLATIVE
BLACK & PUERTO RICAN CAUCUS
* Required




 Male   Female

MD
MBA
PHD
MPH
JD
MS
Student
Other












Physician
Scientist
Educator
Other Professional

Please Check Appropriate Registration Fee: ON OR BEFORE OCT. 20 AFTER OCT. 20
Non-UConn Physician CME $200 $250
UConn Faculty/Researcher and NMA member CME $100 $150
Health Professionals/Allied Health Professional (social workers (CEC), Public Health Workers (CHES), Nurses (CE)) This also includes: Professional Counselors, Marriage and Family Therapists and Psychologists.
$75 $100
Community Member/Other $50
$75
Resident/Fellow/Graduate Student $30 $45
Other Students $15
$20

Yes  No
Free with Summit Registration $0.00

Non-Summit Attendee Per Person $20.00




Yes  No


Credit Card






$

Cancellation Policy: Cancellations must be requested in writing via e-mail to Info@TheCobbInstitute.org by October 20, 2016 to receive a refund. A 25% fee will be assessed to cover administrative costs. There are no refunds for no-shows or for cancellations received after October 20, 2016; however, substitutions are welcome without penalty. We reserve the right to cancel this activity due to unforeseen circumstances. In the event of such cancellation, only the registration fee will be returned to the registrant. W. Montague Cobb/NMA Health Institute will not be responsible for travel expenses incurred by the participant in case of cancellation. Due to PayPal's policies, any refunds will take 7-10 days to be processed by PayPal and reflected back onto the individual's credit card. This is a PayPal policy and should not reflect onto the event sponsors - Cobb, CICATS, or UConn Health.

Accommodations for Disabilities: Please notify the Cobb Institute within a minimum of 10 working days in advance of the event if a reasonable accommodation for a disability is needed.



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The National Health Disparities Elimination Summit