<h2>Registration</h2><p><strong>October 1st &amp; 2nd, 2009</strong></p><form name="mail" action="http://www.siue.edu/cgi-bin/FormMail.pl" method="post"> <h3><input name="required" type="hidden" value="name,phone-number,email" /><input name="print_blank_fields" type="hidden" value="1" /><input name="subject" type="hidden" value="Strategic Planning Summit Registration Form" /><input name="redirect" type="hidden" value="http://www.siue.edu/pharmacy/pain/thanks_registration.shtml" /><input name="recipient" type="hidden" value="PainSummit09@siue.edu" />Personal Information</h3> <table border="0" cellspacing="0" cellpadding="2"> <tr valign="top"> <td> <div align="right"><label for="name"><strong>Name:</strong></label></div> </td> <td><input name="name" size="40" type="text" id="name" /></td> </tr> <tr valign="top"> <td> <div align="right"><label for="degree"><strong>Degree:</strong></label></div> </td> <td><input name="degree" size="40" type="text" id="degree" /></td> </tr> <tr valign="top"> <td> <div align="right"><label for="address"><strong>Address:</strong></label></div> </td> <td><input name="address" size="40" type="text" id="address" /></td> </tr> <tr valign="top"> <td> <div align="right"><label for="city"><strong>City:</strong></label></div> </td> <td><input name="city" size="40" type="text" id="city" /></td> </tr> <tr valign="top"> <td> <div align="right"><label for="state"><strong>State/Province:</strong></label></div> </td> <td><input name="state" size="40" type="text" id="state" /></td> </tr> <tr valign="top"> <td> <div align="right"><label for="zip"><strong>Zip:</strong></label></div> </td> <td><input name="zip" size="40" type="text" id="zip" /></td> </tr> <tr valign="top"> <td> <div align="right"><label for="email"><strong>E-Mail:</strong></label></div> </td> <td><input name="email" size="40" type="text" id="email" /></td> </tr> <tr valign="top"> <td> <div align="right"><label for="practice-site"><strong>Practice Site/Affil.:</strong></label></div> </td> <td><input name="practice-site" size="40" type="text" id="practice-site" /></td> </tr> <tr valign="top"> <td> <div align="right"><label for="name-on-badge"><strong>Name to be printed on your Badge:</strong></label></div> </td> <td><input name="name-on-badge" size="40" type="text" id="name-on-badge" /></td> </tr> <tr valign="top"> <td> <div align="right"><label for="phone-number"><strong>Phone Number:</strong></label></div> </td> <td><input name="phone-number" size="40" type="text" id="phone-number" /></td> </tr> </table> <p></p> <h3>Emergency Contact Information</h3> <table border="0" cellspacing="0" cellpadding="2"> <tr valign="top"> <td> <div align="right"><label for="contact-name"><strong>Contact Name:</strong></label></div> </td> <td><input name="contact-name" size="40" type="text" id="contact-name" /></td> </tr> <tr valign="top"> <td> <div align="right"><label for="contact-relationship"><strong>Relationship:</strong></label></div> </td> <td><input name="contact-relationship" size="40" type="text" id="contact-relationship" /></td> </tr> <tr valign="top"> <td> <div align="right"><label for="contact-daytime-phone"><strong>Daytime Phone:</strong></label></div> </td> <td><input name="contact-daytime-phone" size="40" type="text" id="contact-daytime-phone" /></td> </tr> <tr valign="top"> <td> <div align="right"><label for="contact-evening-phone"><strong>Evening Phone:</strong></label></div> </td> <td><input name="contact-evening-phone" size="40" type="text" id="contact-evening-phone" /></td> </tr> </table> <p></p> <h3>Workgroup Selection</h3><span style="text-decoration:underline">Indicate the workgroup(s) you would like to attend. Please note that workgroups run simultaneously.</span> <table border="0" cellspacing="0" cellpadding="2"> <tr valign="top"> <td><input name="standards-and-assessment" type="checkbox" value="Standards and Assessment - Workgroup #1" id="workgroup-selection" /></td> <td> <div align="left"><label for="workgroup-selection"><strong>Standards and Assessment - Workgroup #1</strong></label></div> </td> </tr> <tr valign="top"> <td><input name="workgroup-selection" type="checkbox" value="Curriculum - Workgroup #2" id="curriculum" /></td> <td> <div align="left"><label for="curriculum"><strong>Curriculum - Workgroup #2</strong></label></div> </td> </tr> <tr valign="top"> <td><input name="workgroup-selection" type="checkbox" value="Residency and Fellowship Standards - Workgroup #3" id="residency-fellowship-standards" /></td> <td> <div align="left"><label for="residency-fellowship-standards"><strong>Residency and Fellowship Standards - Workgroup #3</strong></label></div> </td> </tr> <tr valign="top"> <td><input name="workgroup-selection" type="checkbox" value="Certificate Program Core Content #4" id="certificate-program-core-content" /></td> <td> <div align="left"><label for="certificate-program-core-content"><strong>Certificate Program Core Content #4</strong></label></div> </td> </tr> <tr valign="top"> <td><input name="workgroup-selection" type="checkbox" value="Certificate Program Practice Site-dependent Content - Workshop #5" id="certificate-program-practice-site-dependent" /></td> <td> <div align="left"><label for="certificate-program-practice-site-dependent"><strong>Certificate Program Practice Site-dependent Content - Workshop #5</strong></label></div> </td> </tr> <tr valign="top"> <td><input name="workgroup-selection" type="checkbox" value="Credentialing - Workgroup #6" id="credentialing" /></td> <td> <div align="left"><label for="credentialing"><strong>Credentialing - Workgroup #6</strong></label></div> </td> </tr> </table> <p></p> <h3>Travel and Meals</h3> <table border="0" cellspacing="0" cellpadding="2"> <tr valign="top"> <td><input name="travel-and-meals" type="checkbox" value="I will be arriving by plane and will require ground transportation between the summit and hotels" id="arriving-by-plane" /></td> <td> <div align="left"><label for="arriving-by-plane"><strong>I will be arriving by plane and will require ground transportation between the summit and hotels (Please note transportation from the airport to the conference is not provided. Shuttle service contact information is provided on the previous page)</strong></label></div> </td> </tr> <tr valign="top"> <td><input name="travel-and-meals" type="checkbox" value="I will be arriving via automobile and require a parking pass be sent to me prior to the meeting" id="I-will-be-arriving-via-automobile" /></td> <td> <div align="left"><label for="I-will-be-arriving-via-automobile"><strong>I will be arriving via automobile and require a parking pass be sent to me prior to the meeting</strong></label></div> </td> </tr> <tr valign="top"> <td><input name="travel-and-meals" type="checkbox" value="I will require a vegetarian meal" id="I-will-require-a-vegetarian-meal" /></td> <td> <div align="left"><label for="I-will-require-a-vegetarian-meal"><strong>I will require a vegetarian meal</strong></label></div> </td> </tr> </table> <p></p> <h3>Contact information</h3> <table border="0" cellspacing="0" cellpadding="2"> <tr valign="top"> <td><input name="contact-information" type="checkbox" value="I do not wish to have my name and contact information provided in the on-site attendee list" id="contact-information" /></td> <td> <div align="left"><label for="contact-information"><strong>I do not wish to have my name and contact information provided in the on-site attendee list</strong></label></div> </td> </tr> <tr valign="top"> <td></td> <td><input name="Submit" type="submit" value="Submit" /></td> </tr> </table></form>