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2021 MI Family Medicine Virtual Advocacy Day Registration

Basic Information

* First Name

* Last Name

Degree / Designation

MDDONPPAFAAFPMPHMBAOther

* Home Address

* Home City

* State

* Zip Code

* Phone Number

* Email Address

Special Needs and/or Dietary Restrictions

* Membership Affiliation

MAFP MemberMAOFP MemberBothNeither/Don't Know

If the state representation for your workplace is different from your home, do you wish to attend additional meetings?

YesNoNeither/Don't Know

If yes, enter your Work Address

Work City

State

Work Zip Code

Registration Type

2020 MI Family Medicine Advocacy Day - Free - $0.00

Michigan Academy of Family Physicians | 2164 Commons Parkway | Okemos, MI 48864 | phone: 517.347.0098 | fax: 517.347.1289

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