2015 ORS/OREF/AAOS New Investigator Workshop
Clinical, Translational, and Basic Science Research
WORKSHOP APPLICATION
May 15-16, 2015 ● Rosemont, IL
Application Deadline: March 2, 2015
Please email this application and all supporting documents to lewsza@ors.org.
(DO NOT PDF YOUR DOCUMENTS)
►Completed Application
►Letter of Nomination
►NIH Biosketch of the Applicant (Template)
►Profile Page
►Housing/Registration Form (Please note, your credit card will only be charged if your application to attend is accepted)
First Name
Last Name
Credentials
Institution
Department
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Phone#
PAST & CURRENT RESEARCH ACTIVITIES / GRANT INFORMATION
Project Title
Project Funding:
Amount
Source
Type
Amount
Source
Type
Project Title
Project Funding:
Project Title
Project Funding:
Amount
Source
Type
Research Collaborations
Discipline specialization and sub-specialty
Listing of publications
OREF Grant Recipient?
Do you plan to submit a
grant proposal?
YES
NO
If yes, what year?
YES
NO
If yes, you will have to submit your proposal for faculty to review by March 15, 2015
2015 ORS/OREF/AAOS New Investigator Workshop
Clinical, Translational, and Basic Science Research
PROFILE PAGE
This page will be published in the workshop’s syllabus
pending your application acceptance.
Photo
Please upload your high resolution photo (minimum 300 dpi)
Double click on the image icon to upload your photo
,
First Name Middle Initial Last Name Credentials/Degree
Current Position:
Field degree was earned in:
Current Institution:
Personal Statement (250-300 words)
Career Goals (250-300 words)
Orthopaedic Areas of Interest
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2015 REGISTRATION / HOUSING FORM
Please return this form to the ORS office by March 2, 2015.
Fax: 847-823-5772 or Email: lewsza@ors.org
2015 ORS/OREF/AAOS New Investigator Workshop
MEETING DATES:
MEETING SITE:
Friday - Saturday, May 15-16, 2015
Westin O’Hare, Rosemont, IL
Friday, May 15
8:00 am – 5:30 pm
Saturday, May 16
8:00 am – 2:00 pm
HOUSING SITE:
Westin O’Hare, Rosemont, Illinois
6100 N. River Road, Rosemont, IL 60018
Check-in Time: 3:00pm, Check-out Time: 12:00pm
PARTICIPANT INFORMATION
YOUR NAME
.
ADDRESS
CITY/STATE/ZIP
PHONE
FAX
EMAIL
List any food
allergies or
indicate if you are a
vegetarian
$750 REGISTRATION FEE INCLUDES:
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Housing ( 2 nights: Thursday, May 14 and Friday, May 15)
Meals provided on Friday, May 15 and Saturday, May 16
Networking and Collaboration Dinner (Casual)
Workshop materials
CREDIT CARD INFORMATION:
American Express
VISA
Credit Card #:
Print Name of Card Holder:
Signature of Card Holder:
MasterCard
Exp Date:
Room rate of $159 will be honored May 12-16 if you plan to arrive early or extend your stay. This room rate excludes
of taxes, currently at 13%, resort charges, and service charge.
NOTE: Attendee is responsible for incidentals, all spouse/guest expenses, and any extra night(s) at the hotel
not related to the workshop
SLEEPING ACCOMMODATIONS
Arrival Date:
Departure Date:
Smoking
Single Occupancy
King Bed
Non-Smoking
Double Occupancy
Double Bed
If ADA (Americans with Disabilities Act) accommodation is desired, please specify:
Click here to enter text.
All reservations are guaranteed for late arrival (after 6:00 PM) by the Orthopaedic Research Society.
If you request a sleeping room and fail to notify the staff liaison or hotel directly of a cancellation prior to
11:00 AM of the day of arrival, you will be billed for one night’s sleeping room cost by the ORS.
FRIDAY, MAY 15, 2015:
NETWORKING & COLLABORATION DINNER
You are invited to the networking and collaboration dinner on Friday evening (6:30pm – 9pm) for all faculty and
participants.
I WILL ATTEND
SATURDAY, MAY 16, 2015:
I WILL ATTEND
I WILL NOT ATTEND
WORKING LUNCH, MEETING WITH MENTORS, NETWORKING &
COLLABORATION (12:10PM – 1:50PM)
I WILL NOT ATTEND (I have an early flight)
GRANT: WILL YOU BE SUBMITTING A GRANT PROPOSAL?
YES
NO
Proposal must be submitted by March 15, 2015 to metoyer@oref.org. Please use the NIH Form 398 for an R03,
R01, or K award
PLEASE COMPLETE AND RETURN THIS FORM BY MARCH 2, 2015
TO: Jola Lewsza
FAX: 847/823-5772 E-MAIL: lewsza@ors.org
If you have questions, please call the ORS office at 847-430-5022.