Welcome!
NCSP 2024 Annual Meeting Registration
We look forward to your participation at the NCSP 2024 Annual Meeting! Please note that attendance is by invitation only. Please register by Friday, September 6, 2024.
- A headshot (PNG/JPEG, not exceeding 50 MB)
- Brief biography (200 words maximum)
Personal Information
First Name
Last Name
Middle Initial
Credentials (e.g., PhD, MD, etc.)
Title
Institution/Organization
Email
CC/personal email
Assistant email
Mobile phone number that you can be reached at during the conference:
Bio
Do you require any ADA accommodations? Please select Yes No
Please specify ADA accommodations:
At the time of the conference, will you require lactation accommodations? Please select Yes No
LinkedIn URL
X (formerly Twitter) handle
T-shirt size (unisex style)Size is not guaranteed; some sizes may have limited availability. Please select XS S M L XL XXL
Name Badge
Preferred first name as you would like it to appear on your name badge
Preferred last name as you would like it to appear on your name badge
Pronouns for name badge Please select She/her/hers He/him/his They/them/theirs Prefer not to state Other Other
Meals and Morning Social Activities
Do you have any dietary restrictions? Please select Yes No
Please specify dietary restrictions:
Will you attend the Pre-Conference Dinner on the evening of Monday, November 18, 2024, 6:00 pm-8:00 pm PT, at the UCLA Luskin Conference Center? Please select Yes No
Will you attend dinner on the evening of Tuesday, November 19, 2024, 6:30 pm-8:30 pm PT, at the UCLA Faculty Club? Please select Yes No
Will you attend dinner on the evening of Wednesday, November 20, 2024, 6:30 pm-8:30 pm PT, at the Annenberg Community Beach House? Transportation will be provided. Please select Yes No
Please select any on-site, morning social activities below in which you are interested in participating: Affiliation
What is your affiliation? Please select Current NCSP Scholar Alum (RWJF Clinical Scholars, NCSP, including NCSP 'third-year' Scholars) Current NCSP Faculty (including Program Directors, Associate Directors, etc.) Current NCSP Staff Invited Speaker NCSP National Program Board Member Invited Guest
Site (please select one of the following options): Please select Duke University University of California Los Angeles University of California San Francisco University of Michigan University of Pennsylvania Yale University
Year (please select one of the following options): Please select First-year Scholar Second-year Scholar
Profession (please select one of the following options): Please select Nurse Physician
Primary Specialty: (Please select one): Please select Anesthesiology Emergency Medicine Family Medicine Internal Medicine Neurology Obstetrics/Gynecology Pathology Pediatrics Psychiatry Surgery Urology Other Other
Program (please select one of the following options): Please select RWJF Clinical Scholars NCSP
Enter Site:
Fellowship Years (e.g., 2000-2002)
Fellowship Years (e.g., 2000-2002)
Speed Mentoring Preferences
On November 20, 2024, from 9:30 am-10:40 am PT, we will be holding a speed mentoring session. Each scholar will have 2-3 scheduled one-on-one speed mentoring meetings (10 to 15 minutes each) with NCSP faculty, alumni, community members, board members, and/or invited conference speakers. OPT OUT. We expect that you will attend unless you inform us that you cannot make it or are not interested in participating.
Opt out Topics of Interest (Please check all that apply-Current NSCP Scholar): Please specify which clinical specialty or research related to a clinical specialty (Current NSCP Scholar)
Please specify health policy areas of interest (Current NSCP Scholar)
Please specify non-academic career pathways of interest (Current NSCP Scholar)
Anything else you would like us to know-Current NCSP Scholar?
On November 20, 2024, from 9:30 am-10:40 am PT, we will be holding a speed mentoring session. Each scholar will have 2-3 scheduled one-on-one speed mentoring meetings (10 to 15 minutes each) with NCSP faculty, alumni, community members, board members, and/or invited conference speakers.
As NCSP Faculty, your participation is integral to the success of this event!
We have a particular need for speed mentors in surgical fields.
RSVP: Please select Yes, I will participate in the speed mentoring session. No, I will not participate in the speed mentoring session.
Topics of interest (Please check all that apply-Current NSCP Faculty): Please specify which clinical specialty or research related to a clinical specialty (Current NSCP Faculty)
Please specify health policy areas of interest (Current NSCP Faculty)
Please specify non-academic career pathways of interest (Current NSCP Faculty)
Anything else you would like us to know-Current NCSP Faculty?
On November 20, 2024, from 9:30 am-10:40 am PT, we will be holding a speed mentoring session. Each scholar will have 2-3 scheduled one-on-one speed mentoring meetings (10 to 15 minutes each) with NCSP faculty, alumni, community members, board members, and/or invited conference speakers.
We would love to have you share your wisdom and experience and help build the Clinical Scholars/NCSP network!
(Please note that third-year NCSP scholars who opt to participate will be included in the mentee pool.)
We have a particular need for speed mentors in surgical fields.
R.S.V.P: Please select Yes, I will participate in the speed mentoring session. No, I will not participate in the speed mentoring session.
Topics of interest:- (Please check all that apply-Alum) Please specify which clinical specialty or research related to a clinical specialty (Alum)
Please specify health policy areas of interest (Alum)
Please specify non-academic career pathways of interest (Alum)
Anything else you would like us to know-Alum?
On November 20, 2024, from 9:30 am-10:40 am PT, we will be holding a speed mentoring session. Each scholar will have 2-3 scheduled one-on-one speed mentoring meetings (10 to 15 minutes each) with NCSP faculty, alumni, community members, board members, and/or invited conference speakers.
We would love to have you share your wisdom and experience and help build the Clinical Scholars/NCSP network!
We have a particular need for speed mentors in surgical fields.
RSVP Please select Yes, I will participate in the speed mentoring session. No, I will not participate in the speed mentoring session.
Topics of interest (Please check all that apply-Speaker) Please specify which clinical specialty or research related to a clinical specialty (Speaker)
Please specify health policy areas of interest (Speaker)
Please specify non-academic career pathways of interest (Speaker)
Anything else you would like us to know-Speaker?
On November 20, 2024, from 9:30 am-10:40 am PT, we will be holding a speed mentoring session. Each scholar will have 2-3 scheduled one-on-one speed mentoring meetings (10 to 15 minutes each) with NCSP faculty, alumni, community members, board members, and/or invited conference speakers.
We would love to have you share your wisdom and experience and help build the Clinical Scholars/NCSP network!
We have a particular need for speed mentors in surgical fields.
R.S.V.P Please select Yes, I will participate in the speed mentoring session. No, I will not participate in the speed mentoring session.
Topics of interest: (Please select all that apply-NCSP National Program Board Member) Please specify which clinical specialty or research related to a clinical specialty (NCSP National Program Board Member)
Please specify health policy areas of interest (NCSP National Program Board Member)
Please specify non-academic career pathways of interest (NCSP National Program Board Member)
Anything else you would like us to know-NCSP National Program Board Member?
On November 20, 2024, from 9:30 am-10:40 am PT, we will be holding a speed mentoring session. Each scholar will have 2-3 scheduled one-on-one speed mentoring meetings (10 to 15 minutes each) with NCSP faculty, alumni, community members, board members, and/or invited conference speakers.
We would love to have you share your wisdom and experience and help build the Clinical Scholars/NCSP network!
We have a particular need for speed mentors in surgical fields.
RSVP:- Please select Yes, I will participate in the speed mentoring session. No, I will not participate in the speed mentoring session.
Topics of Interest (Please check all that apply-Guest):- Please specify which clinical specialty or research related to a clinical specialty (Guest)
Please specify health policy areas of interest (Guest)
Please specify non-academic career pathways of interest (Guest)
Anything else you would like us to know-Guest?
Release and Assumption of Risk
As an in-person attendee of the NCSP 2024 Annual Meeting (Los Angeles, CA), I acknowledge that I cannot hold NCSP, its partners, sponsors, and staff liable should I contract COVID-19 or other illness, sustain injury, or for expenses incurred if I need to cancel due to travel restrictions imposed by local, state, national or international jurisdictions.
2. I knowingly and freely assume all such risks related to illness and infectious diseases, such as COVID-19, even if arising from the negligence or fault of the Released Parties.
3. I hereby knowingly assume the risk of injury, harm, and loss associated with the NCSP 2024 Annual Meeting, including any injury, harm, or loss caused by the negligence, fault, or conduct of any kind on the part of the Released Parties.
I AGREE TO THE RELEASE AND ASSUMPTION OF RISK.
By registering to attend the National Clinician Scholars Program 2024 Annual Meeting, and in connection with my participation in the Meeting, I consent to the use of my name, photograph, video or other likeness in the promotional and other materials of the Meeting without payment or other consideration made to me. I waive the right to inspect or approve any such use of my name or likeness. I expressly release the Meeting sponsors, their trustees, officers, agents, employees, licensees, and assignees, from any and all claims, including copyright, privacy, and defamation arising out of any exhibition, publication, or promotion of this Meeting. I understand that the Meeting may also be available on the sponsors’ websites and archived formats.
I AGREE TO THE CONSENT AND RELEASE STATEMENT. Payment
Alumni are offered a greatly reduced, non-refundable conference registration fee of $325. Registration will not be considered complete until payment is made.
Please make your payment via credit card at the following link by Friday, September 6, 2024 :
https://commerce.cashnet.com/
You will receive a separate registration confirmation from annualmeeting@nationalcsp.org within one to two business days after payment has been made.
I ACKNOWLEDGE THAT MY REGISTRATION WILL NOT BE COMPLETE UNTIL I HAVE PAID THE ALUMNI REGISTRATION FEE OF $325 BY SEPTEMBER 6, 2024.
Please review and submit your registration
