16th Annual Doctors for Global Health General Assembly

Title:

First name: *

Last name: *

Street address: *

City: *

State: *

Zip: *

Phone:

Email: *

Your email address will be used to send registration confirmation. We promise not to spam you. We will never sell or give someone else your email.

Title/Position:

Institution/Affiliation:

DGH GENERAL ASSEMBLY REGISTRATION: Please pick ONE of the following options

(see below to register for the People’s Health Movement USA planning meeting)

Full Registration

I will attend the conference Friday evening through Sunday afternoon and will need dorm lodging on Friday and Saturday nights (2 persons/room) at Loyola Marymount. This registration also includes conference fees, the Friday night social, all meals on Saturday and Sunday, and the Saturday night dinner/social event.

Developed country registration sliding scale:
Early bird registration: $150 - 400 (double occupancy) or $230 - 480 (single occupancy).
After May 31^st: $200 - 400 (double occupancy) and $280-480 (single occupancy)

(Pay more if you can, less if you can’t. GA ‘break-even’ cost is $230/person. By paying a higher amount, you’ll help us meet our expenses & share cost of bringing our international guests to Los Angeles)

Developing country registration: $10

Registration Contribution*: Based on the above suggested amount, please enter your contribution to serve as registration payment: $

Day Registration ONLY

I will attend the conference only and do not need overnight accommodations (students, local participants). This registration includes conference fees, all meals on Saturday and Sunday, and the Saturday night dinner/social event but does NOT include the Friday night social, which will cost an additional $20 to be paid at the door.

Select the day(s) you plan to attend:

Saturday

Sunday

STUDENTS:

Single day sliding scale: $40-70.

Two-day sliding scale: $70-100.

NON-STUDENTS:

Single day sliding scale: $60-100.

Two-day sliding scale: $90-140.

Registration Contribution*: Based on the above suggested sliding scale, please enter your contribution to serve as registration payment: $

FRIDAY AFTERNOON TOUR

Please select your participation:

I WILL

I will NOTparticipate in the Friday afternoon tour of Father Greg Boyle's Homeboy Industries and tour of Skid Row outreach services and health clinics. This tour leaves Loyola Marymount at 1:00pm on Friday, Jul 29, with a return by 5:00pm. There is a $10 transportation fee.

PEOPLE’S HEALTH MOVEMENT USA PLANNING MEETING July 28th-29th

Please indicate your preference and pick ONE of the following registration options:

I DO

I do NOTplan to attend the PHM-USA planning meeting Thursday and Friday before the General Assembly, July 28th-July 29th.

Full Registration

I will attend the PHM-USA conference Thursday at noon through Friday at noon prior to the GA and will need dorm lodging on Thursday night at Loyola Marymount. This registration also includes conference fees, lunch on Thursday and breakfast and lunch on Friday.

Fee:

Single Occupancy: $155
Double Occupancy: $110

PHM Registration Fee: Based on the above fee structure, please enter the amount to serve as PHM registration payment: $

Day Registration ONLY

I will attend the PHM-USA conference Thursday at noon through Friday at noon prior to the GA and do not need accommodations (students and local participants). This fee includes conference registration and lunch on Thursday and breakfast and lunch Friday.

Day fee: $55 (Thursday and Friday included)

PHM Registration Fee: Please enter the amount to serve as PHM registration payment: $

FRIDAY NIGHT DINNER

Please indicate your preference:

I DO

I do NOTplan to attend the Friday night dinner, silent auction fundraiser, and networking opportunity at Jyoti and Gilbert’s home, long-time members of Doctors for Global Health.

Number of guests, if any (rough estimate): I also plan to bring friends to this event that is open to the public

(guests and day-registrant-only participants: $20 suggested donation at the door.
please note that no one will be turned away for lack of funds).

OPTIONAL

Continuing Medical Education credits for physicians

Continuing Medical Education (CME): Harbor-UCLA Medical Center designates this educational activity for a maximum of 7 hours of Category 1 credit toward the American Medical Association’s Physician’s Recognition Award (PRA) and the California Medical Association’s Certification in Continuing Medical Education. Physicians should claim only the credit commensurate with the extent of their participation in the educational activity.

Cost: $100

Will your children be attending as well?

Children are welcome; please add following costs accordingly

Number of Children:

Additional Cost: $ (Please add $45 per child for food, $35/night extra per child for dorm room accommodation)

Do you need additional overnight accommodations?

Dorm rooms are available for $45/person per night one night before and after the conference.

Nights I need:

Thursday (It is included if you selected PHM - Full Registration; but check here anyway to be sure you're counted)

Sunday

Extra nights total cost: $

Would you also like to contribute to DGH work?

I would also like to contribute to DGH work: I am including $ as a tax-deductible donation to DGH

Sandy Kemp

I would like to help DGH give persons who want to attend but cannot afford the conference costs the opportunity to attend: I am including $ to the Sandy Kemp Memorial Scholarship fund

TOTAL PAYMENT

Total Payment: * I am paying a total of $ (Note: any amount paid above the break-even GA cost of $230 is tax-deductible)

Please add the total for DGH registration, PHM meeting, costs for CME credit, children and extra nights if applicable, and any other donations amount from above.

I am paying by the following: *

Credit Card. (via DGH website, no fees) Please click "Pay by credit card" to make an on-line payment by credit card BEFORE clicking on "Submit" below. Enter total payment in "Donation Amount (USD)" on the credit card page

Check. Please make check payable to Doctors for Global Health and indicate that it is for the GA 2011 with the participant’s name. PRINT THIS FINAL REGISTRATION FORM and send it with your check to DGH, P.O. Box 1761, Decatur, GA 30031.

Questions?

* E-mail dghassembly@dghonline.org should questions arise. *