Department of Continuing Medical EducationFaculty Hotel Accommodation FormWe are so excited to have you join us for the 59th Annual Pediatric Postgraduate Course.Please complete the following form as soon as possible so that we may secure your accommodation for the course. NOTE:If you are logged in, the fields below will be automatically completed using the information in your user profile - please edit the information as needed. Main Guest Details Prefix * First Name * Last Name * Additional Guests * Will there be additional guests staying with you? Yes No Additional Guest DetailsEnter up to one additional named guest below. First Name Last Name Separate Bills? * YesNo Total # of Adults Total # of Children Booking DetailsARRIVAL AND DEPARTURE DATESArrival and Departure dates are subject to approval by CME Staff.Speaking faculty may be granted a one-night stay for their presentation day, arriving the day prior or the day of.If you need additional dates, please contact CME staff at cme@nicklaushealth.org or enter a comment in the field provided. Requested Arrival Date * Month MonthMar Day Day21222324 Year Year2024 Requested Departure Date * Month MonthMar Day Day22232425 Year Year2024 Room Type * - Select -Double (2 Queen Beds)Single (1 King Bed) Notes/Special Requests Enter any additional notes here for the hotel staff Address * Telephone Number * Email Address * Additional Comments or Notes Use this space to provide any additional details for NCHS Staff Disclaimer & Additional InformationPlease be aware that there may be additional fees incurred for accommodating additional guests, which may not covered through our booking. Additional charges and incidentals are the responsibility of the guest unless otherwise arranged.By entering my name below I attest to having read the disclaimer above, that the information I entered in this form is correct, and that I will update CME staff immediately should any changes be needed. Name * Leave this field blank
