Presenting Resident/Fellow Accompanied or Unaccompanied by a Preceptor Registration Form For presenting residents/fellow accompanied or unaccompanied by a preceptor. (All of the following fields are required. Please enter N/A if any required answers are not applicable. For example, you would enter N/A for middle initial if you did not have a middle name.) If you are not presenting or are a preceptor, sponsor or student, please click here to register. Last Name:     First Name:     Middle Initial:     Institution:     Street Address of Institution:     City:     State:     Business Phone:     Email Address:     Preceptor Attending Conference:     Please enter title of submission.     Please enter the name(s) of the author(s) separated by commas. Omit degree designations.     Presenter Name (omit degree designations):     Check ONE of the following practice interest categories for this submission:   Primary care/ambulatory care Clinical Services Management (pharmokinetics, nutritional support, etc.) Internal medicine Infectious Disease Pediatrics/Neonatology Hematology/Oncology Critical Care Cardiology Community Practice Practice Management (management issues, MUE's, pharmoeconomics, etc.)     REGISTRATION TYPE / FEE: (See below for registration payment information.)   Registration for residents/fellows accompanied by a preceptor $150 Presenting Residents/Fellow Unaccompanied by a Preceptor $200     HOTEL ACCOMMODATIONS AT THE CONFERENCE: (See below for details about hotel accommodations). Name of Roommate:     Name of Institution:     Special Instructions / Requests:     Please indicate your planned day of arrival by checking the appropriate date in order to facilitate the room reservation process: (All presenters are expected to be at the conference by 8:00 AM Friday, May 9th.)   Thursday, May 8th Friday, May 9th     Planned Day of Return: Please indicate your planned day of return by checking the appropriate date in order to facilitate the room reservation process.   Saturday, May 10th Sunday, May 11th     PAYMENT INFORMATION: Make Checks Payable to: Midwest Pharmacy Residents Conference Mail a copy of your registration form and payment to: Dana J. Lambert Office Coordinator, Pharmacy/Pathology Services THE NEBRASKA MEDICAL CENTER 988485 Nebraska Medical Center Omaha, NE 68198-8485 Phone: 402-559-4412 Fax: 402-559-4741 Email:   HOTEL ACCOMMODATIONS AT THE CONFERENCE: Hotel reservations will be made by conference personnel for all residents and fellows from within the Midwest region accompanied by a preceptor. Please include your preferred roommate in the provided space. If you do not specify a roommate, one will be assigned at random. If a preceptor is planning on sharing a room with a resident, the conference must be notified. The preceptor will still be responsible for their room charges. Presenters who request a private room will be charged for half of the cost of the room. Private room requests will be accepted space permitting. TRAVELING TO THE CONFERENCE: Please see the traveling information page for further information.