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Eliminate Tobacco Use Summit 2023

Registration Form

The Eliminate Tobacco Use Initiative is excited to host the 8th annual Eliminate Tobacco Use Summit designed to address the key areas of policy, prevention education and cessation treatment services among institutions of higher education.

The Eliminate Tobacco Use Summit creates a collaborative environment for academic institutions along with key state and national partners and stakeholders to share best practices and increase their network and community of support.


Select your registration type for the national summit: *
Please confirm that you are attending the in-person National summit (on April 27th) in Texas:

to include continental breakfast, lunch, networking reception, and parking

Do you plan to attend a state Summit? *

In addition to the national summit (April 27th)

National Summit Networking Reception

Would you like to attend the after-summit networking reception on Thursday, April 27th from 3pm – 4pm?

Process

Virginia summit attendees - Please let us know where you are in the process of tobacco free higher education at your institution:

Please mark all that apply to you: *

Preferences

Dietary Restrictions *

Do you have any dietary restrictions?

Dietary Preferences

Please indicate which (check all that apply):

Please indicate your food allergies:

Will you need a lactation/quiet room?
Do you have any accessibility needs? *

Please indicate your accessibility requirements:

Will you need parking?
Do you plan to receive continuing education credit for your attendance? *

I.e. CEU (Continuing Education Units), CME (Continuing Medical Education), or CECH (Continuing Education Contact Hours). Additional charges apply.

Which CEs do you intend to receive? *
Contact Information

Please indicate the pronouns you'd like shown on your name badge

Shipping/Mailing Address

By agreeing to the terms and conditions, you grant The University of Texas MD Anderson Cancer Center (MD Anderson), its representatives, and employees the right to take photographs and/or recordings of you in connection with the Eliminate Tobacco Use Summit. You authorize MD Anderson to copyright, use, and publish the same in print and/or electronically. You agree that MD Anderson may use such photographs and/or recordings of you with or without your name for any lawful purpose, including such purposes as publicity, illustration, advertising, and web content. Please contact us if you have questions.

By checking this box I attest that I am not affiliated with the tobacco and/or e-cigarette industry or an agency/institution that accepts tobacco/e-cigarette industry funding.

I attest that I am a student currently enrolled at an accredited college, university, technical or vocational school.

Participant health and safety is our highest priority. We are committed to following guidelines set forth by UT Southwestern, the city of Dallas, and the CDC regarding COVID-19 and other public health concerns. As the summit approaches, leadership will be monitoring the status of the pandemic. Several considerations are outlined below as reminders for those attending the 8th annual Eliminate Tobacco Use Summit in-person.

  • It is always recommended to practice appropriate hand hygiene and respiratory etiquette.
  • While wearing a mask is encouraged, they will not be required to attend this event.
  • If you are experiencing any COVID-19 symptoms or are feeling unwell in any way, you should not attend the summit. Please email event organizers to cancel, with no penalties.
  • Notify event organizers if you become diagnosed with COVID-19 within 10 days after attending the Eliminate Tobacco Use Summit
Payment

Select your payment method

For checks mailed by USPS:
The University of Texas MD Anderson Cancer Center
PO Box 4390
Houston, TX 77210-4390

For checks sent via courier (FedEx, DHL, UPS, etc):
JP Morgan Chase
MD Anderson Cancer Center
PO Box 4390
14800 Frye Rd
Fort Worth, TX 76155

Please include the following notation when submitting payment by check:
172100-30-122685-46

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Order Summary

Total $0

Disclaimers

  1. All cancellations must be submitted in writing by emailing our event manager or canceling your registration through the link in your confirmation email. All registrations will incur a $7.60 cancellation fee.
  2. Refund requests will receive a full refund of their registration cost (less a $7.60 cancellation fee).