Form Template - Planning Committee FD | Children's Hospital Colorado Continuing Education

1 PC Form 2 Financial Disclosure 3 List of Disclosures 4 Sign Off

Planning Committee Form

Thank you for agreeing to participate as a planning committee for the ***Conference Name***, ***Conference Dates***. Please complete the following form.

Name (first and last) *

Email address *

CREDENTIAL LISTING FOR BROCHURE (NAME, CREDENTIALS, ACADEMIC TITLE, EMPLOYER, CLINICAL TITLE, EMPLOYER)

Examples

Kay Kinzie, MSN, RN, FNP-BC
Clinical Manager
Immunodeficiency Program
Children’s Hospital Colorado

Adam Rosenberg, MD
Professor of Pediatrics
University of Colorado School of Medicine
Attending Neonatologist
Neonatal ICU and Special Care Clinic
Children’s Hospital Colorado

Provide your credential listing below *

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Form Template - Planning Committee FD

Planning Committee Form

CREDENTIAL LISTING FOR BROCHURE (NAME, CREDENTIALS, ACADEMIC TITLE, EMPLOYER, CLINICAL TITLE, EMPLOYER)

Examples

Kay Kinzie, MSN, RN, FNP-BCClinical ManagerImmunodeficiency ProgramChildren’s Hospital ColoradoAdam Rosenberg, MDProfessor of PediatricsUniversity of Colorado School of MedicineAttending NeonatologistNeonatal ICU and Special Care ClinicChildren’s Hospital Colorado

Kay Kinzie, MSN, RN, FNP-BC
Clinical Manager
Immunodeficiency Program
Children’s Hospital Colorado

Adam Rosenberg, MD
Professor of Pediatrics
University of Colorado School of Medicine
Attending Neonatologist
Neonatal ICU and Special Care Clinic
Children’s Hospital Colorado