Calendar Submission Form

Name: *

Sponsor/Organization: *

Address: *

City/State/Zip: *

Telephone: *

Fax:

E-Mail:

TITLE OF PROGRAM: *

PROGRAM DATES: *

LOCATION: *

TARGET AUDIENCE: *

REGISTRATION FEE (if applicable):

ESTIMATED ATTENDENCE *

# MDs/Dos # PAs # RNs # PTs/OTs

# Counselors # Other

COURSE DESCRIPTION and/or OBJECTIVES
(Please type, cut and paste, or attach)

PROGRAM AGENDA and FACULTY LIST
(Please type, cut and paste, or attach)

NUMBER OF CREDIT HOURS OFFERED
# MDs/DOs # RNs # OTs # PTs

# BBS # Other
URL ADDRESS (if applicable)

Once completed
or print and send via FAX or mail to:
University of California, San Diego
9500 Gilman Drive, 0617
La Jolla, California 92093-1217
Telephone - 858-434-3240
Fax - 858-554-7642 * Required Fields