Online Registration Form
Enter information in each field, press TAB to move to next field and click CONTINUE to complete your registration.
For your convenience, a "User ID" will be constructed from the first 4 letters of your Last Name + 4 digits you provide below. (It is recommended to use the last 4 digits of your SSN.)
* Required Field
* First Name
* Last Name
*
User ID (Last 4 digits)
****
* Degree
MD
DO
PhD
PharmD
NP
RN
RT Other/Specify:
* Affiliation (Institution, School or Practice)
* Specialty
Radiology
General Surgery
Internal Medicine
Family Practice
Neurology
Vascular Surgery
Cardiology
Dentistry
Orthopedics
* Sub Specialty
Neuroradiology
Breast Imaging
Interventional Radiology
Cardiovascular
Body MR
MSK
Emergency Radiology
Diagnostic Imaging
Thoracic
Computed Tomography
Pediatrics
Research
GI
GU
Nuclear Medicine
Contact Information
* Address1
Address2
* City
* State
--
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
* Zip/Postal Code
* Country
* Email Address
* Primary Phone Number
Alternate Phone Number
Fax Number
Spouse Name
Please select all that apply below
* Attendee Type
Physician
Technologist
Full Time Active Military
VA Personal
Resident/Fellow
(Letter from academic institution required)
Dietary Needs
Kosher
Diabetic
Vegetarian
Alumni
Penn Radiology Alumni
Residency
Fellowship
Both
Year Completed
Complimentary Activites
Family Continental Breakfast
(Monday Morning)
Please type number of adults and children attending
adults
children
Welcome Reception
for registrants/families (Monday Evening)
Please type number of adults and children attending
adults
children
Special Optional Activities
Lobster Dinner Buffet
(Thursday Evening)
Please type number of people attending
@ $76.50 per adult
@ $44.00 per child ages 10-15 (no lobster)
@ $31 per child ages 3-9 (children's buffet)
Lighthouse Tour
(Monday Afternoon)
Please type number of adults and children attending
@ $24 adults
@ $15 children under 16
Historic Walking Tour of Edgartown
(Tuesday Afternoon)
Please type number of adults and children attending
@ $14.50 per adult
@ free per child under 12
Wildlife
Kayak & Canoe Tour
(Tuesday Afternoon)
Please type number of people attending
@ $42 per adult
@ $22 per child under 16
Wildlife
Kayak & Canoe Tour
(Thursday Afternoon)
This activity has been canceled
Historic Walking Tour of Edgartown
(Monday Afternoon)
This activity has been canceled
Lighthouse Tour
(Wednesday Afternoon)
This activity has been canceled
Deep Sea Fishing
(Wednesday, July 9th)
This activity has been canceled
Fee
Payment will be processed through Secure Payment processing
Contact us at:
Registrar, University of Pennsylvania Medical Center, Department of Radiology
1 Founders/3400 Spruce Street, Philadelphia, PA 19104
Phone- 215-662-6982 Fax- 215-349-5925 Email:
cme@rad.upenn.edu