Maine Humanities Council | Lit & Med : Training Institute

Download Lit & Med Brochure (2MB pdf)

Registration

Registering electronically is easy!

There are two steps involved—submitting the registration form to us and then sending your payment by PayPal, credit card or check. First, fill out the form on this page and submit it (instructions are at the bottom of the form). If you would like to use Paypal, click on our PayPal link to pay using either your credit card or PayPal account.

Registration Payment Date/Amount

Early Bird discount: $100 if both payment and completed registration forms are received
by or on May 1. The first 20 registrants will receive a complementary copy of Ten Years of Medicine and the Arts, published by Academic Medicine, the Journal of the Association of American Medical Colleges and edited by Lisa Dittrich. A rich resource!
After May 1st—$150.

Refund Policy

Refunds are available for all fees according to Refund Policy . All refund requests must be in writing (by post, fax or e-mail) and must be received by the deadlines indicated.

Registration is considered complete when both the completed form and full payment has been received. We will send you a confirmation.

Thank you!

* Indicates required field

Participant Information *First Name:

*Last Name:

*Organization:

*I am a (please choose one):

Facilitator

Humanities Council Staff

Hospital liaison/organizer

Preferred Contact Information *Street:

*City:

*State/Province:

*Zip/Mail Code:

*Email:

*Phone Number:

*Phone (please choose one):

Day

Night

Fax:

Contact Information as it should appear on public participant contact list:

*Same as above or see below:

See above

See below

Street:

City:

State/Province:

Zip/Mail Code:

Email:

Phone Number:

Phone (please choose one):

Day

Night

Fax:

Biographical statement for Institute information: *Click here for link to
biographical statement
examples. Please add 100-300
words in the comments
area (you can copy & paste
into this box):

Updates

We will contact you with further updates via email. If you would prefer phone or fax, please fill out the appropriate field below.

Phone:

Fax:

Emergency Contact Information *Emergency Contact:

*Day:

*Night:

Special Requirements I require vegetarian meals:

I require accommodations
in accordance with the
Americans with Disabilities Act:

Please specify needs:

Continuing Education Credits Indicate what type of Continuing Education Credits you will need (if appliable):

Accommodations:

University Center, conveniently located in Downtown Chicago.

All Prices include 3 continental breakfasts, 3 lunches, coffee breaks, 1 dinner (June 22) and 3 nights (June 22-24). *

Quad Semi-Suite, $275.00 per person (a suite with two separate rooms, with two beds each, sharing one bath; each room houses two people. If you sign up for this option, you will have a roommate. )

Quad 4 Bedroom Apartment, $350.00 per person (suite with four private bedrooms and two shared baths).

Do not need overnight accommodations $110.00 (for meals, as described above)

All units are fully furnished and include extra-long twin bed, desk and chair, bookcase, and closet with organizer. Additional amenities include sheets, pillow, pillowcase, blanket, towel, washcloth, soap and shampoo. All units offer internet access and free local calls.

These accommodations are for
the nights of June 22-24.
For extra days before or after
please indicate (we can not
guarantee the availability
of additional days).

*Roommate/suitemate preference: We
will do our best to place
roommate/suitemate preferences together.
We will need to hear from
all parties to finalize (please write “none” if no preference).

Payment Information

*Please let us know what payment method you are using:

Check mailed to: Attn: Annie Medeiros
Maine Humanities Council
674 Brighton Avenue
Portland, ME 04101

Call us with credit card information
(MasterCard or VISA)
Annie Medeiros: (207)773-5051 x217 PayPal

Comments/Questions Please let us know how you heard
about the institute and add any
additional comments or questions:

Submit Form

Press the Red Button to submit this form to us, then print the “Thank You” page that you will then see for your records. If you want to submit payment via PayPal, come back to this page and use a PayPal button below.

Paypal Payment

Registration fee and quad semi-suite,
totaling $425. Please type
your name and "Training Institute" in the "Add special
instructions for the Merchant" box in the PayPal form.

Registration fee and quad four bedroom,
totaling $500. Please type
your name and "Training Institute" in the "Add special
instructions for the Merchant" box in the PayPal form.

Registration fee and meals totaling $260
(before May 1). Please type your name
and "Training Institute" in the "Add special
instructions for the Merchant" box in the PayPal form.

If you have a problem with either form, please contact Annie Medeiros or call (207)773-5051.