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Patient Care

Please complete ALL information below and submit electronically or return to:    Jim Ybarra at FAX No. (518) 262-8460

I have read and understand the Instructions for Coordinating a Videoconference Downlink Site.
My institution will be hosting a site(s) for the videoconference to be broadcast on:  (specific date) 
I have arranged (number of sites) sites in the state of:  
Please estimate the number of attendees:
Please list the cities in which you have confirmed sites:
 
Your Name:         
Phone Number:   
Institution Name:
Address Line 1:  
Address Line 2: Physical Address only. Do not use P.O. Box.
City:
State:
ZipCode:
Fax Number:
Email Address: