"*" indicates required fields First Name*:* Last Name*:* Designation(s):* Specialty: Practice or Organization Name: Email Address*:* Preferred Phone Number: Have you renewed your dues for 2023? Yes No Unsure Please confirm that you have read MCMS's COVID-19 Event Policy.* I have read and agree to the policy. I have questions regarding the policy; please contact me. To access the policy, visit https://www.montgomerymedicine.org/events/upcoming-events-2/covid-19-event-policy/. All attendees must provide proof of COVID-19 vaccination. Please select how you will provide it:* By uploading an image of my vaccine card / MyIR record. I have provided proof of vaccination at an event in the last 90 days. (MCMS staff will verify.) I will resubmit this form with documentation prior to the event date. Upload Proof of Vaccination Here: Drop files here or Select files Max. file size: 32 MB. Staff will verify vaccination status and record it. Images are deleted immediately after review. Emeritus member fee $75 Price: $75.00 Quantity: CAPTCHA Exhibitor Information
