ONLINE EVENT REGISTRATION & PAYMENT

1950s Vegas-Style Casino Night

First Name*

Last Name*

Address*

Address2

City*

State*

Zip*

Phone*

Email*

Tickets ($75 each)

1 Person = $75

2 People = $150

Please enter Guest Name below:

Total Amount

Gross Amount

Payment method

Credit or Debit Card (Processed by Paypal - Does not require a Paypal account.)

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Type*

Card Holder Name*

Verification code*

National Capital Physicians Foundation
15855 Crabbs Branch Way
Rockville, MD 20855

p: 301.921.4300
f: 301.921.4368
info@dedicatedtohealth.org

Executive Director: Susan G. D’Antoni

Program Coordinator: Farhana Arastu

Executive Director: Susan G. D’Antoni

Program Coordinator: Farhana Arastu

The National Capital Physicians Foundation is a 501c3 public charity. The Foundation is tax-exempt as defined by the Internal Revenue Code, and as such, contributions to the National Capital Physicians Foundation are tax-deductible. Tax I.D.# 81-1085170

NOTE: THIS PROGRAM IS NOT FOR PHYSICIANS IN CRISIS.
If you are in crisis, call 911 or go to the nearest Emergency Room.

The Physicians’ Resource Network is an early intervention counseling program to help physicians achieve greater resilience and balance in their professional and personal lives.

When this form is received, you will be contacted within 24-36 hours to confirm an appointment.

All fields must be completed or the form cannot be submitted.