P.O. Box 8158, Wilmington, Delaware 19803
phone: (302) 479-5515   |  fax: (302) 479-5518 | e-mail: delfamdoc@comcast.net

Last Update 17 July 2008
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ENROLLMENT FORM

2008 FALL LECTURE SERIES

(Please print this form and fax or mail it to DAFP: 302-479-5518)

NAME:
Please Print 		___________________________________________ D.O.
M.D.
R.N.
STREET
ADDRESS:
___________________________________________		  
CITY, STATE, ZIP: ___________________________________________  
PHONE: ___________________________________________  
E-mail ___________________________________________  
 FEES:

Physicians registering for the entire series 

$70 for DAFP members; $75 for non-members

 

Nurses/PAs registering for the entire series - $50

 

IIndividual lectures - $15 each  (Note: There is no charge for attending the cancer symposium on 10/22, but separate pre-registration is required)

 

Attn Family Medicine Residents: Admission is free for all lectures, but RSVP is requested
Total Fee Enclosed
Dates (if signing up for individual lectures  
Mail or Fax to:

Delaware Academy of Family Physicians

 P.O. Box 8158, Wilmington, Delaware 19803
phone: (302) 479-5515   |  fax: (302) 479-5518 | e-mail: delfamdoc@comcast.net
 

Delaware Academy of Family Physicians
Beverly Dieffenbach,  Executive Director

DAFP Officers & Directors | DAFP/REF Officers & Trustees | Past Presidents | Committee Chairs | Contact Us