Institution:

Mailing Address:

Address (cont.):

City: State: Zip:

Country:

Email: Work Phone:

Cell Phone: Fax:

AACN Member: Yes No (membership not required)

Student, Intern or Resident: Yes No

ABSTRACT (not to exceed 200 words)
Poster Section: Adult Pediatric

Number of Authors: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

                 First Name  Middle Initial  Last Name

Title:

ABSTRACT INSTRUCTIONS: Please provide a summary of your presentation, including background, specific scientific aims, design and methodology, main findings, and conclusions. Maximum 200 words.

Abstract:

ABSTRACT CLASSIFICATION: Please rank the two content areas which best categorize your abstract. Select a 1 for the primary categorization and 2 for the secondary categorization.

1    2	1    2
Alzheimer's Disease	HIV/AIDS
Attention	Intellectual Functioning
Brain Tumors	Language Disorders
Cerebrovascular Disease	Learning Disabilities/ADHD
Cross Cultural Issues	Medical Disorders
Dementia/Aging	Memory
Demyelinating Disorders	Movement Disorders
Developmental	Neuroimaging
Epidemiology	Neuropsychological Testing
Epilepsy	Parkinson's Disease
Executive Functioning	Psychiatric Disorders
Forensic	Traumatic Brain Injury
Genetics	Visuospatial Functions
Other:

AUTHOR PERMISSION TO PUBLISH ABSTRACT:
Corresponding author must authorize AACN the right to publish your abstract in The Clinical Neuropsychologist (TCN). In consideration of AACN reviewing and editing this abstract submission, the author hereby transfers, assigns or otherwise conveys on behalf of all authors ownership of this abstract to AACN in the event that this abstract is published. The author warrants that this abstract is original and holds AACN harmless for any and all defects or claims arising from its publication. I AGREE

CONFLICT OF INTEREST DECLARATION:
Corresponding author must complete.
1.a. Will your presentation include any commercial products or services?
         Yes No (If No, skip to question 2)
1.b. If Yes, do you have a significant financial interest or other relationship with the manufacturer(s) of any of the products(s) or provider(s) of the products or services referenced in your presentation?
         Yes No (If No, skip to question 2)
     If Yes, please list the manufacturer(s) or provider(s) and describe the nature of the relationship(s):
    
2. Please list any and all sources of funding that supported the work described in your presentation:
    

UNDERSTANDING AND AGREEMENT:
I confirm that the information contained in this submission form is accurate. I understand and agree to the terms of this agreement.

AACN MEETING REGISTRATION INFORMATION: Corresponding authors must register for the meeting to be eligible to present their work. For questions, please contact Pamela McMurray via email: pamela.mcmurray@phci.org or by phone: 262-928-2652.