Medical Society Consortium Draft

Registrant Information

First Name: Required Field

Last Name: Required Field

Primary E-mail: Required Field

E-mail Address Type: Required Field

If you plan to participate in Visits with Legislators (in person), your home address/where you live is required.

Home Address: Required Field

City:

State:

Zip:

Area Code: Required Field

Phone Number (ex: 5551234): Required Field

Phone Type: Required Field

Primary relationship to Mason: Required Field

Please list any dietary needs/restrictions in the space provided:

Are you a member of the media?

I agree to have my name and contact information shared with The Medical Consortium for further communications. Required Field

I agree to have my name and contact information shared with The Medical Consortium for further communications. Yes
No

Affiliation

Organization

Title:

Medical Society, if applicable (type out full society name):

Affiliate organization, if applicable (type out full org name):

Please select your Consortium affiliation (select all that apply):

Use Ctrl or Shift keys to multi-select.

I am a medical/nursing/health professions student. Required Field

I am a medical/nursing/health professions student. Yes
No

Up to 4 Continuing Medical Education (CME) credits will be available to attendees for participation in Sunday and Monday morning sessions. Please choose which session(s) you will be attending:

Legislative Visits

The Consortium will host a required training session for those intending to visit with their Legislators. We are only able to schedule congressional visits for advocates attending in-person. There will be no virtual congressional meetings available in conjunction with the 2023 Annual Meeting. Congressional visits may be scheduled up to 4 p.m. on March 21. Please make travel plans accordingly. Information regarding hotel accommodations will be sent via registration confirmation and can also be found on our website.

Do you plan to participate in visits with Legislators in person? Required Field

A member of the Consortium advocacy team will be in touch if you selected “I would like to know more.”

Please note: if you plan on meeting with legislators, we will be sharing your contact information with the necessary parties.

Ticket Options

Choose your ticket: Required Field

$155 of the Sustainer ticket price is a charitable contribution to the Consortium.

Are you paying with a company/corporate credit card?

Company Name (if applicable):

Contact [email protected] if paying for the Annual Meeting presents a financial burden.

Contact Dawn Cassidy, development operations manager, at 703-993-3164 or [email protected] if you prefer to pay via check or electronic funds transfer in lieu of the online credit card process.

Your registration and payment will be processed by George Mason University Foundation, with proceeds going directly to the Consortium.

Make a Gift

Gifts to the Medical Society Consortium on Climate and Health accelerate our mission in advocating for equitable climate solutions that protect and promote the health of all people.
Gifts to the Sarfaty Fund for Climate, Health and Equity honor our founding executive director and support the Consortium’s most urgent outreach efforts.

Remove	Name	Amount
	Medical Society Consortium on Climate and Health (a program of George Mason University)	$
	Mona Sarfaty Fund for Climate, Health and Equity	$
Total:	$0.00	0%