Tri-State Stroke Network - Register for Conferences and CME

* 1. First Name:

format: Alpha only

* 2. Middle Initial:

format: one Alpha character, no period

* 3. Last Name:

format: Alpha (dash, comma, apostrophe allowed)

4. Suffix:

(degree or credentials; 15 characters max.)

* 5. Employer:

* 6. Job Position Title:

* 7. Work Phone:

format: ###-###-####

* 8. Work Email Address:

* 9. Work Mailing Address:

Enter up to 200 characters. Characters Remaining =

* 10. Are you a Tri-State Stroke Network Member?

Yes No

* 11. Are you requesting Continuing Medical Education Credits?

Yes No

If "Yes", then please download and complete the UNC-CME Biographical Form (DOC, 42 KB) and send it to us via Email.

12. Are you interested in joining our listserv?

Yes No

To finish requesting registration, please complete the reCAPTCHA image verification challenge below (if displayed) and press the "Submit Request" button.

As noted above, you need to enable Javascript in your browser in order to use this form. If that is not possible or is troublesome, you may recommend this site using your local, client-based email program or a web-based email program. Return to the TSSN Home Page.

Alternate Registration Method

If registration using the form below presents problems (e.g., completion of the image verification challenge is not possible because you are using a screen reader), please use the Email software installed on your computer or a free, web-based Email program, such as Gmail (Google), Yahoo!, or Hotmail (MSN), to Email us.

reCAPTCHA Information

Why are you being asked to complete the reCAPTCHA challenge? The reCAPTCHA, 3rd-party image verification tool helps identify the user as a human (rather than a spam-generating computer) and reduces the likelihood of this form being used for unintended purposes.

reCAPTCHA Quick Help:

If you use the audio challenge, type the numerals/digits without spaces (do not spell out the numbers).
If you use the image-based challenge each word you type should be separated by a space.
If you don't like your challenge, click the refresh button to the right of the response field to get a new one.
If you need further help, click the question mark ("?").

Why are there 2 words in the reCAPTCHA puzzle? A full summary can be found at http://recaptcha.net/learnmore.html. Solving the reCAPTCHA puzzle improves the process of digitizing scanned books by sending words that cannot be read by computers via Optical Character Recognition (OCR) to the Web in the form of CAPTCHAs for humans to decipher.