Online Registration - Research Seminar Series



Printable form (PDF) 

* = required field.  If you have registered before for another of our programs, you only need to update these fields to register.  If any of your other information has changed, please keep us up to date!

 Thursday, May 1, 12:00-1:00 pm CST - Keeping Our Arteries Healthy As We Age: Evidence for traditional and lifestyle therapies - David N. Proctor, PhD 

Name:  *First:   *Middle:   *Last: 

*Email Address (needed for confirmation): 

CE Type needed: CME   CNE   ACHA-Resident   Social Work    Certificate of Attendance       No CE   

*Where/how will you be attending this/these program(s)?

 In person - Kansas City, KS - University of Kansas Medical Center, Landon Center on Aging, Room 270 
 Web-Based - Adobe Connect
 ITV - Atchison, KS - Dooley Center, 801 S. 8th Street
 ITV - Fairway, KS - KU Alzheimer's Disease Center, KU Clinical Research Center, Overland Park Room 1238, 4350 Shawnee Mission Parkway
 ITV - Great Bend, KS - St. Rose Ambulatory & Surgery Center, St. Dominic Classroom, 3515 Broadway (Not available 5/1)
 ITV - Hays, KS - KUMC Northwest Area Health Education Center, 205 E. 7th Street, Suite 130  
ITV - Hutchinson KS - Hutchinson Regional Medical Center 1701 East 23rd Street, Conference Room C
 ITV - Leoti, KS - Wichita County Hospital, Conference Room, 211 E. Earl
 ITV - Pittsburg, KS - KUMC East Area Health Education Center, 1501 S. Joplin, 4th floor
 ITV - Sabetha, KS - Sabetha Community Hospital, Hospital Board Room, 14th and Oregon
 ITV - Sterling, KS - Sterling Presbyterian Manor, 204 W. Washington
 ITV - WaKeeney, KS - Trego County Lemke Memorial Hospital, 320 N. 13th Street
 ITV - Wichita, KS - Kansas Masonic Home, 401 S. Seneca
 ITV - Wichita, KS - KU School of Medicine-Wichita, 1010 N. Kansas (room TBA)
 ITV - Winfield, KS - Kansas Veterans' Home, 1220 WW II Memorial Drive 

Workplace Information

Organization Name:  

Mailing Address: 

City:   State:  Zip Code:  - 

Phone:      Fax: 

Home Information
Note: Home Mailing address is need to send CE certificate

*Mailing Address: 

*City:   *State:  *Zip Code:  - 

Phone:      Cell Phone: 

Preferred Mailing Address:  Home    Work

Professional License Type:   


License Number:  State:  (type US if National)

Additional Professional License Type:   


License Number:  State:  (type US if National)

Other Credentials: 

Participant Profile

Funding support for this program is being provided by a grant to the Central Plains Geriatric Education Center from the Health Resources and Services Administration, Department of Health and Human Services.  As a requirement of this Federal funding, we must report aggregate information about all of those who attend these programs.  The information you provide is confidential and will only be used in reporrting to HRSA.  You only need to provide this profile information the first time you register for a program in this series, or if/when the information you have provided to us previously needs to be updated.

Gender: Male     Female 

Year of Birth: 

Ethnic Background:  Are you Hispanic/Latino?  Yes     No

Ethnicity: If Asian, Specify Country:

Do you consider yourself to have ever been from an economically or educationally disadvantaged background?  No     Yes

In which of the following areas did you grow up (the area in which you spent the most time before age 18)?
Rural   Suburban   Urban   Not Applicable
Frontier (remote site where weather or distance can prevent immediate transport to acute care facility)

Highest Education Level:   Please Specify Degree:

Discipline or Profession (pick ONE category that best describes your discipline/profession):     

What is your Position/Job Title? 

Primary Occupational Role:     

Are you Retired?  Yes     No

Site of Practice - Please check if you work in any of the following sites:
Do you work in a rural setting? Yes     No
Do you work in an urban setting? Yes     No
Do you work in a medically underserved community?  Yes     No

If you are a health care practitioner and spend at least 50% of your time serving underserved populations (e.g. low income/low socioeconomic status, limited access to care, geographically isolated, etc.) please check the site of practice.  If not, select "None/NA".



Last modified: Apr 25, 2014

MS 1005
3901 Rainbow Blvd.
Kansas City, KS 66160

General Correspondence: 
(913) 588-3179

(913) 945-7846

(913) 588-1464