Diabetes Center at UCSF - Registration Form 2009

Retreat Information Registration Form Recharge Form Directions & Map Program Schedule

Diabetes Endocrinology Research Center (DERC)

DERC was established to support and enhance interactions among an outstanding team of investigators involved in Type 1 or 2 diabetes research.

UCSF JDRF CENTER (CCCT)

The mission of the center is to develop and test a new approach to the treatment of Type 1 diabetes by bringing together researchers from 5 academic institutions and 1 commercial partner.

Registration Form 2009

April 7-8, 2009 Asilomar Conference Center 800 Asilomar Boulevard Pacific Grove, California 93950 http://www.visitasilomar.com/	Registration Deadline: February 23, 2009 Registration Fee: $50 (meals & lodging)

Please complete the online registration form. Please note, if you are staying an additional night on April 8, there will be an additional charge of $25. If you would like to attend the IRM Retreat, please register for it separately at http://irm.ucsf.edu/News/Retreat.aspx by February 13.

Retreat Information | Recharge Form | Directions & Map | Program Agenda

Personal Information (* Required Field)

Title: *

UCSF Faculty

DERC Member

Postdoc Fellow

Clinical Fellow

Student

Other (Specify)

Gender: *

Male Female

First Name: *

Last Name:*

PhD

MD, PhD

Other

Email:*

Telephone: *

- -

Department: *

Address: *

City: *

State: *

Zip Code: *

T-shirt size

If you're a Postdoc Fellow or student, please complete below:

PI's Name:

PI's Email:

Will you present a Poster? Deadline: February 23, 2009

Yes (please provide the title of your poster below):

Lodging Information:

Do you need to stay overnight? Note: First-come/first-serve basis.

Yes (please list the order of roommate preferences below)

Will you stay for the Keynote Speaker and the IRM Poster Session on the evening of 4/8?

Yes

Will you need a room for the evening of 4/8 (please note there is an additional $25.00 charge)?

Yes

Emergency Contact Information (* Required Field)

In case of EMERGENCY, please notify:

Name:*

Relationship:

Daytime Phone: *

Evening Phone: *

Payment Method (* Required Field)

How would you like to pay for the registration fee? *

Check (Make check payable to UCSF Regents & mail it to)

UCSF Diabetes Center
C/O Amy Lam
513 Parnassus Ave., Box 0534
San Francisco, CA 94143-0534
Tel#: 415.476.1609 Fax#: 415.731.3612

UCSF Recharge (download Recharge form below)

>> Recharge Authorization Form <<

Request waiver (Note: Fees are waived on a case-by-case basis.)

If you would like to register for the IRM Retreat, please do so at the following link by February 13, http://irm.ucsf.edu/News/Retreat.aspx.

Retreat Information | Recharge Form | Directions & Map | Program Agenda