UPMC Hillman Cancer Center

Satellite and Retreat Registration

Deadline for registration is Wednesday, June 6, 2018 at 4 pm.

  1. Registrant Information   *All fields are required unless otherwise noted. Form does not accept special characters (&, /).
  2. First Name:  
    Last Name:
    Position:
    Degree(s): (MD, PhD, etc.)
    Academic Title:
    Primary Department:
    Laboratory Affiliation:
    (IF applicable, e.g., Dr. John Smith. )
    Area of Research or Disease Site Affiliation:
    Address below is: Office Lab
    Room / Suite / Lab:
    Street Address:
    City / Town:
    State:
    ZIP Code:
  3. Contact Information
  4. Email:
    Home or Cell Phone Number:
    Attending (please mark all applicable days):
    Wednesday Satellite Thursday Retreat Friday Retreat
    Will you be attending dinner?
    Yes - Wednesday Yes - Thursday Not attending either dinner
    Will you be submitting an abstract? Yes No
  5. Accommodations - For Wednesday, June 20, and/or Thursday, June 21, 2018 Only*
  6. *Any changes to, or cancellations of, housing requests must be submitted by June 7, 2018 to Lisa George at georgel@upmc.edu. Please note that you will be assessed a charge of $50.00 if you request housing and do not attend the satellite and/or retreat for which you registered, or you do not cancel your reservation by the June 7, 2018 deadline.

    Please reserve a room for me on:

    No - Do not reserve a room for me

    Wednesday June 20 (available only for Satellite Conference attendees)
    Thursday June 21
    Gender: Male    Female
    Please indicate with whom you would like to share a suite, if known.
    Use a space or dash (-) to separate names – field does not accept commas,
    semi-colons, colons, etc.

    (all people listed must register separately for the satellite and/or retreat):
    Do you need a handicap accessible room? Yes    No
  7. Special Dietary Needs
  8. Please note that vegetarian selections are available at every meal/break.

    None   Kosher Food   Gluten-Free Food   Nut Allergy

    Shellfish Allergy