First Name *

Last Name *

Organization (e.g., Hospital/Health System, Community-Based Organization, College/University, Health Insurance Provider, Private Practice/Clinic, Government Agency, Other) *

Title (e.g., Physician, Nurse, Social Worker, Executive/Administrator, Instructor/Faculty, Student/Trainee, Other) *

Email *

Email (Confirmation) *

How are you planning on attending the Upcoming Medical Ethics Colloquy on Monday, March 23? *
I'll be attending the event in-person at the Loosemore Auditorium in the Richard M. DeVos Center.
I'll be streaming the event virtually.

Have you attended the DeVos Medical Ethics Colloquy before? *
Yes, I have attended the DeVos Meical Ethics Colloquy in the past.
No, this will be my first time attending a DeVos Medical Ethics Colloquy.

Are you a student (any college/university)? *
- Select Option Yes No

Are you interested in receiving continuing education credits for the DeVos Medical Ethics Colloquy? *
- Select Option Yes No

Please indicate type of credit you would like to receive for the Colloquy. *
- Select Option CME Nursing Social Work

Please indicate your SW license number *

Please include your nursing license #

Do you need any special accommodations? If so please specify.