Register for the UVA Alumni and Friends Reception - American Academy of PM&R 2023 Annual Assembly

To register for the UVA Alumni and Friends Reception at the American Academy of PM&R 2023 Annual Assembly on November 18, please complete the form below.

First Name*
Last Name*
Preferred Nametag Name*
Preferred Email Address*
UVA Affiliation*
SOM Class Year
Preferred Telephone Number*
Will you be bringing a guest(s)?*
- Yes
- No
Guest Information
Name of Guest
SOM Affiliation + Class Year (optional)
Is guest an adult or child?
- Adult
- Child age 2 or older
- Child under age 2
Additional Information
Does anyone in your party have any mobility restrictions?*
- Yes
- No
If yes, please briefly explain (please reference name of attendee)
Does anyone in your party have any dietary restrictions?*
- Yes
- No
If yes, please briefly explain (please reference name of attendee)

First Name*
Last Name*
Preferred Nametag Name*
Preferred Email Address*
UVA Affiliation*
SOM Class Year
Preferred Telephone Number*
Will you be bringing a guest(s)?*
- Yes
- No
Guest Information
Name of Guest
SOM Affiliation + Class Year (optional)
Is guest an adult or child?
- Adult
- Child age 2 or older
- Child under age 2
Additional Information
Does anyone in your party have any mobility restrictions?*
- Yes
- No
If yes, please briefly explain (please reference name of attendee)
Does anyone in your party have any dietary restrictions?*
- Yes
- No
If yes, please briefly explain (please reference name of attendee)

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Register for the UVA Alumni and Friends Reception – American Academy of PM&R 2023 Annual Assembly

Guest Information

Additional Information

Guest Information

Additional Information