Event Registration

Your Registration
Your Name:


First Name*


Last Name*


Suffix


 

Your Contact Information:


Address 1

 


Address 2

 


City

 


State

 


Zip

 


(###)


###


####

Cell or Home Phone
 


Email Address*

 Event Details:

Which event would you like to attend?* 

Including yourself, how many will be attending?*

Please list any guests that will be joining you:

Select your affiliation:*

Please select if you have any dietary restrictions:

If "Other", please provide a brief description:

 



Security Measure

If you have any questions or problems regarding your event registration process please email us at MedComm@uic.edu or call the Office of Medical Advancement at (312) 996-4470.

Please note our events may be photographed for promotional purposes. By registering for this event you are consenting to having your photo taken and these photos may be shared online, used in print publications or on social media channels. Please let us know if you prefer to not be photographed or identified in any photography. Contact us directly if you have any questions via email at MedComm@uic.edu.