2018 Premedical Conference Group Registration Form
Thank you for your interest in our conference. Please fill out all the required information to complete your registration.
First Name of Representative
(The person completing the form)
Middle Initial of Representative
Last Name of Representative
Full name of High School, College, or University
High School Junior
High School Senior
Pre-med/ Pre-Health advisor
Representative Phone Number
Representative E-mail Address
Apt/ Room Number
Group Members List
Group registration should be completed by downloading the UTMB Premed Conference Group Registration Form (Word document). The form can be accessed at
. Please submit the completed form by email to
Do any of the participants have special dietary needs? Please specify type and how many participants.
(Example: vegetarian x 3)
If participant(s) will require any special accommodations during the conference, please specify below:
Registration Payment and Deadline
The fee for general registration is $12 per person. The deadline to submit your payment is March 30, 2018.
Please indicate which method of payment you will be using to pay your registration fee. If paying by debit or credit card, please download the payment form from the conference website.
Check (Make payable to UTMB Health)
Money Order (Make payable to UTMB Health)
Individuals will pay separately
Please mail check or money order to: UTMB Health, 301 University Blvd. Galveston, TX 77555-1308.
If you have any questions or concerns, please contact LeTanya Neely at (409) 772-3763 or Email:
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