Committee of Interns and Residents/SEIU Healthcare

2010 CIR National Convention

“Health and Wellness: Our Patients, Our Hospitals, Ourselves”

May 21 – 23, 2010

Hyatt Regency Philadelphia at Penn’s Landing Philadelphia, PA

Email Address: *

First Name: *

Last Name: *

Address: *

City: *

State/Province/Region: *

Zip/Postal Code: *

Mobile Phone: *

Hospital: *

Department/Specialty:

PGY:	Degree: M.D. D.O. D.P.M. D.D.S. D.M.D. Other

Room Reservation

If you share a room with another attendee, CIR will pay the full cost of the room ($250.00 per night double occupancy) at the Hyatt Regency Philadelphia at Penn's Landing. If you wish your own room, you will be charged half the cost of a room ($125.00 per night.)

Roomate Preference: *

  I want my own room, and understand that I will pay $125.00 per night.
  Please choose a roommate for me -- I am female.
  Please choose a roommate for me -- I am male.
  I already have the approval of another doctor to share a room with him/her.

I have approval to room with Dr.:

You must provide a current credit card when you arrive at the hotel. Any incidental expenses you incur during the convention (phone calls, room service) will be charged to your credit card. If you cancel 72 hours before your scheduled arrival date, you will not be responsible for any charges.)

Dietary Restrictions: *

  None
  I do not eat meat
  I do not eat meat or fish
  Other

Other Dietary Restrictions (please specify):

Travel, Arrival and Departure Information

Please make your plane or train reservations with UN Travel: Call (800) 234-8685 and indicate that you are attending the CIR convention.

PLEASE NOTE that the CIR 2010 National Convention begins on Friday, May 21 at 6:30 pm with registration and reception at the Hyatt Regency Philadelphia at Penn's Landing.

I will arrive in Philadelphia, PA: *

Friday, May 21
Saturday, May 22 (note: the convention begins at 8:30 am sharp!)

At what time: *

AM/PM: *

AM
PM

I will leave Philadelphia, PA: *

Saturday, May 22
Sunday, May 23

At what time?: *

AM/ PM: *

AM
PM

I will travel by: *

  Plane
  Train
  Car
  Other

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