Registration Form

SRS & SBRT Delivery with Eclipse and TrueBeam Conference





If you have questions about the course content, please contact Dr. John Fiveash at (205) 975-0224 or jfiveash@uabmc.edu



If you have questions regarding registration or travel logistics, please contact Lindsay Pruett at (205) 934-4763 or lindsaypruett@uabmc.edu



Cancellation Policy We ask that you provide us with a 40 day notice should you wish to cancel. Cancellations should be sent via email to Lindsay Pruett



You may be entitled to this training as part of your agreement with Varian. Otherwise, there is a fee to participate in the conference. For questions regarding this fee, contact Lindsay Pruett at 205.934.4763. Please make check payable to UAB Department of Radiation Oncology. Mail your check to 1700 6th Avenue South, Room 2252, Birmingham, AL 35233 to the attention of Joey Slatsky. Please include your registration number to ensure your payment is properly processed.


Are you receiving this training as part of your Varian equipment purchase?

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Please indicate which dates you will attend:(*)

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Employer/Affiliation

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Contact name(*)

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Address(*)

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City

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Country

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Telephone number

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Fax number

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Email(*)

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How did you learn about us?

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Please indicate the name, credentials, and role for each person attending. There is a maximum number of four participants for each group.



Participant 1 Information


1 Name

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1 Credentials

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1 Role

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1 Email

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Participant 2 Information


2 Name

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2 Credentials

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2 Role

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Participant 3 Information


3 Name

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3 Credentials

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3 Role

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Participant 4 Information


4 Name

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4 Credentials

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4 Role

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4 Email

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Are there any dietary restrictions?

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If yes, please briefly explain:

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You may review your submission before submitting by using the PREV button. Use the SUBMIT button to complete the registration.




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