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Pediatrics 2040 Young Innovators Workshop Application
The below application is to apply to take part in the Pediatrics 2040 Young Innovators Workshop being held at the InterContinental Hotel, Miami, FL on January 4th and 5th, 2017.

Application reviews will be done on a rolling basis.

Parents, please help your children fill out the form. You will be contacted via email or phone number provided on the application.

In addition to the below form, please submit a 1-3 minute video describing a problem/pain point that you think needs solving in the healthcare industry. (if you have ideas for a solution, please include in your video)

Please submit your video and application as early as possible, and before December 24, 2016.

First Name *
Your answer
Last Name *
Your answer
Age *
Your answer
Participant or parent email address *
Your answer
Parent name *
Your answer
Parent cell phone number *
Your answer
What idea do you have that is, or will help solve, a problem in pediatric healthcare? *
(Ideas stemming from personal experiences are encouraged)
Your answer
The event will be held on January 4th and 5th, 2017 in Miami, FL as part of the Pediatrics 2040 conference. Can you be there for the entire time? *
Are your/the child's parents attending the conference? *
Do you have technology that you can bring to the event to work on your project? *
Required
Do you have other items you can bring to help work on your project?
Please Describe
Your answer
Do you have any interests, talents, or hobbies that might help your team or another team? *
Required
Why do you want to be part of the Pediatrics Young Innovators Event? *
Your answer
Do you have interest in continuing to work on a project after the workshop is over?
Do you give permission for Peds2040 to publicly share your child's idea video as part of our marketing and/or other promotional material? *
(PARENTS NEED TO ANSWER FOR ALL CHILDREN UNDER THE AGE OF 18)
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