ACEP ID:

Leader Visit Request Form

Important

Requests should be submitted as early as possible and at least 2 months prior to the meeting date in order to ensure leader availability and to avoid high airfare. Requests received too close to the meeting will not be considered.

For rotation leader visits, Chapter Services budgets one hotel night for the leader. Should the chapter exceed the number of nights allowed, they are responsible for the remaining nights & expenses. 

Visit Information

Request Primary and Alternate Leaders  (do not select the same leader more than once)

Is CME being offered through ACEP?

Yes

No

Meeting Information

If hotel and meeting location are the same, please click yes or no below

Yes

No

Will chapter reserve a room for leader

Yes

No

Hotel Location

Meeting Location

Specific Presentation(s) Requested

The leader must provide a 15 to 30-minute update to the chapter about national ACEP activities and issues.

National ACEP Update (Required)

Presentation #2 (Refer to the Leader Visit Topics)

Multiple or single choice

Physicians

Nurses

Residents

PAs

EMTs

Chapter Contact Information

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