Home Dialysis Academy

Wednesday, January 22, 2020 - Friday, January 24, 2020 

 
 Registration Information - Required fields are marked *
*
First Name
Middle Name
*
Last Name
*
Degree
*
Specialty
*
Fellowship Program Name
*
Office
*
Address1
Address2
*
City
*
State
*
Zip
Country
*
Email
*
Phone
Alt Phone
Fax
   Comments
    

Registration Fee
Registration Fee (Non-refundable) $50.00
 
Number of Extra Tickets  

Payment Method
 Check or UAB Internal Transfers-Only accepted with prior approval from UAB administration
 Credit Card

Travel Grants
A limited number of travel grants of $300 will be available on a first come first serve basis, however travel stipends are not guaranteed to all participants.
Will you be applying for a travel grant?
YesNo

Checks and letters of good standing should be mailed to:
1900 University Blvd, ZRB 633
Birmingham, AL 35294

Sponsored by Baxter Healthcare Inc. and Davita