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Center for Medical Simulation (CMS)

100 First Avenue, Suite 400
Boston, MA 02129-2011
Phone: 617-726-3034
Fax: 617-726-3046
Email: info@harvardmedsim.org
Website: https://www.harvardmedsim.org

MOCA®/Crisis Resource Management Training for Practicing Anesthesiologists (ACRM) Application Form

Anesthesiologists on staff at BIDMC, BWH, BCH, and MGH should apply through their department schedulers.

* Required

* Course Name / Date:
Prefix: Mr Ms
* First Name:
* Last Name:
Discipline: Physician
Specialties:
Title:
* E-Mail Address:
* Institution Name:
* Institution Address 1:
Institution Address 2:
* City:
* State:
* Postal Code:
* Country:
* Telephone Number:
* Please tell us how you heard about this course:
* If you prefer that your tuition invoice be sent directly to a billing department, please specify the
Name, Email Address, Phone Number and Mailing Address to whom the invoice should be sent here:
Please enter any other information you feel would help us in setting up your course:
*
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Submission Hints:

Upon successful completion of this form, after clicking the 'Submit' button, you will be redirected to an Application Submitted page and you will receive a confirmation email containing a copy of your application.

Please click the 'Submit' button only once. The form submission often takes up to a minute. You may receive the confirmation email before you see the Application Submitted page. We appreciate your patience.

TUITION:

USD $1,900.00

ENROLLMENT POLICY:

You will be informed of acceptance to your selected course/workshop by email within two weeks of our receiving your completed application. Your tuition is due immediately upon acceptance. Once accepted you will receive another email containing an invoice with payment instructions. Please note that acceptance does not mean enrollment. Once accepted, you are placed on a wait list. You are not enrolled, and do not have a reserved seat, until we have received your full tuition.

Course seats are filled in the order we receive tuition payments. Since our courses fill quickly it is important for you to send in your tuition immediately to secure a seat. Once your tuition payment is received, you will be taken off the wait list and enrolled in your desired course/workshop provided a seat is still available. If all seats in your preferred course/workshop are filled by the time we receive your tuition payment, you will be informed that it is full and given the option to remain on the wait list in the event that a seat later become available; switch to another course at a later date with available seats or receive a refund.

PAYMENT INFORMATION:

The Center for Medical Simulation accepts payment by credit card, wire transfer, money order or cashier’s check in US dollars. Personal checks are not accepted. You will be receiving an invoice via email from Rhonda Young. Your payment is due immediately upon receipt. If you would like to pay by credit card there is a link in your invoice that you can click on, or paste into a browser, that will take you to a page on our website where you can make your payment. If would like to make payment by any other method please contact Rhonda Young at ryoung@harvardmedsim.org.

Most problems paying by credit card are due to using an older version of the Internet Explorer, Chrome or Firefox browsers. Also, some organizations may block your ability to pay for services online. If you encounter problems, try updating your browser and/or paying from your home computer. If you are still having problems, please contact us at info@harvardmedsim.org.

CANCELLATION POLICY:

If you must cancel we will refund your tuition less a $100 processing fee provided another paid candidate is able to fill your seat. Otherwise, you will forfeit half your tuition.

If you would like to switch to a course offered at a different date, we will apply your tuition towards the new course provided another paid candidate is able to fill your current seat. Otherwise, you will forfeit half your tuition. If you still want to switch to another course date we will apply half of your paid tuition and you will be billed for the remaining half. Please note that the tuition for a course offered at a later date may be higher. In that case, individuals switching to the later course date will need to pay the difference in the tuition fees.

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  Anesthesia Course Director
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