MPRC

• First Name
• Last Name
• Email Address
• Phone (###-###-####)
• Institution Name
• Street
• City
• State
• Zip
• JUDGE/MODERATOR ASSIGNMENTS (please select multiple) Primary Care/Ambulatory Care Clinical Services Management Internal Medicine Infectious Disease Pediatrics/Neonatology Hematology/Oncology Critical Care Cardiology Community Practice Pharmacy Practice Transplant Psych
• Special Requests (i.e. dates/times available or unavailable to judge/moderate). Respond N/A if none.

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Event Waiver/Disclaimer

**PRECEPTOR REGISTRATION FEES HAVE BEEN WAIVED FOR THE 2021 VIRTUAL CONFERENCE**

All registered preceptors will be REQUIRED and ultimately scheduled to be a judge and/or moderator at this years event

• I have read and agree to the terms of the event waiver/disclaimer:  Yes     No

REGISTRATION FEES

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