Pediatric Mental Health Outreach Symposium -Durango, CO- Planning Committee Reply Form

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

Planning Committee Form

Thank you for participating on the planning committee for the 2025 Pediatric Mental Health Outreach Symposium on September 8 and 9, 2025. Please complete the following form.

Name (first and last) *

Please provide your credentials and titles below:

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

List your credentials and titles here: *

Email address *

Cell phone *

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Planning Committee Form

Please provide your credentials and titles below: