Media Registration Form

Please fill out this form for each member of the media wishing to attend AAFP events. (Only working media will be allowed to register; sales and public relations staff cannot be registered as media.)

Fields marked with a * are required.

* Freelance writers must submit a letter of assignment or letter of intent from the media outlet being represented. Letters can be e-mailed from assigning editor to Barbara Kowalski at bkowalsk@aafp.org or faxed to 913-906-6089.

Please review the All Event Media Guidelines prior to registering for this meeting.

Note: Media attending the AAFP Scientific Assembly are allowed to enter strictly for viewing/reporting purposes only. The soliciting of exhibitors and/or physicians is strictly prohibited. Any company or publication representative that solicits exhibitors or physicians will be considered in violation of AAFP rules and regulations. If such a violation occurs, the representative's company will not be allowed to attend, in any capacity, future AAFP meetings. The AAFP reserves the sole right to determine if a violation has occurred and to remove the solicitors and/or their company from the exhibit floor. Exhibitors and physicians have been asked to inform the convention staff of any solicitations they receive.

*Event: Have you covered this event before? Yes No Are you covering a particular topic or event? Yes No If yes, please note:
*Date of request (today's date):
*Name: (first, last)
*Position/Title: (correspondent, editor, writer, photographer, etc.)
*Affiliation: (publication, station/channel, *freelance, etc.)
*Street Address:
*City:
*State:
*ZIP Code:
Phone Number:
Fax Number:
*E-mail: