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Course Selection & Date

Course Name*

Preferred Date*

Please complete the form below to apply for a simulation instructor training course or workshop. You will be informed of your acceptance and next steps by email.

Please complete the form below to apply for a labor and delivery teamwork training course. You will be informed of your acceptance and next steps by email.

For American Board of Obstetrics and Gynecology (ABOG) diplomates participating in the Maintenance of Certification (MOC) process:

Your ABOG ID number is required to complete this form

For American Board of Anesthesiology, Inc. (ABA) diplomates participating in the Maintenance of Certification (MOC) process:

Your American Board of Anesthesiology, Inc. (ABA) ID Number is required to complete this form
Your American Society of Anesthesiologists (ASA) ID Number is required to complete this form

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

Please indicate if you are applying as a member of a team or as an individual who wishes to be assigned to a team*

Member of a Team
Individual (assign me to a team)

Please indicate your team name*

This can be your institution and department or another name that all of your team members use to indicate that you are all on the same team

Please enter the name of the team leader, the primary contact person for your team.*

First Name* Last or Family Name*

Please enter the best email address to contact your team leader.*

Enter Email Confirm Email*

Please enter (and confirm) the best email address to contact your team leader. Your team leader will receive a confirmation of this application sent to this address.

Registrant Information

Prefix

Mr.
Ms.
Mx.

First Name* Last or Family Name*

Primary Discipline*

What is your clinical specialty?*

Clinical examples might be anesthesia or emergency medicine. A non-clinical example might be organizational behavior. For applicants who are no longer practicing clinically, please tell us your previous clinical background.

What is your job title or current role?*

e.g. Associate Program Director, Fellow in Medical Simulation, Clinical Nurse Specialist, Program Manager of Simulation, Staff Development Specialist

What are your credentials or educational degrees?*

e.g. MD, RN, MSN, PhD, EdD, EMT-p, MEd, MPH

American Society of Anesthesiologists (ASA) ID Number*

Fill in your American Society of Anesthesiologists (ASA) ID Number here to receive credit for the Maintenance of Certification in Anesthesiology (MOCA®) Part IV Simulation Requirement

American Board of Anesthesiology, Inc. (ABA) ID Number*

Fill in your American Board of Anesthesiology, Inc. (ABA) ID Number here to receive credit for the Maintenance of Certification in Anesthesiology (MOCA®) Part IV Simulation Requirement

Are you an ABOG Diplomate participating in the Maintenance of Certification (MOC) process?*

Yes
No

ABOG ID Number*

Fill in your ABOG ID Number here to receive credit for the Improvement in Medical Practice (Part IV) MOC requirement

Contact Information

Telephone*

Email Address* Confirm Email*

Please enter (and confirm) the best email address to contact you. You will receive a confirmation of this application sent to this address.

Institution Name*

Please enter the name of your institution, hospital, simulation center, university, or other affiliated organization.

Institution Address*

Street Address Address Line 2 City State/Province ZIP/Postal Code Country

Please enter your institution mailing address. (work address)

Is the billing contact information the same as applicant contact information?*

Yes
No

Billing Information

Please enter the name of the person responsible for tuition payment.*

First Name* Last or Family Name*

Please enter the best email address to contact your billing person.*

Email Address* Confirm Email*

What is the best telephone number to reach your billing person?*

Billing Address*

Street Address Address Line 2 City State/Province ZIP/Postal Code Country

Please enter your billing address. (work address)

Other Information

Please tell us how you heard about this course*

Please enter any comments or other information you feel would help us in setting up your course

Please let us know in the space provided below if you have any special requests such as accommodation for severe food allergies. We will do our best to help meet your needs but please understand that we may not be able to accommodate every request. This is especially true for dietary requests due to limitations set by our vendors. If you prefer to bring your own food, we have a kitchen space with a microwave and refrigerator available. We also have a private space that can be used for pumping or administering medication.

If you wish to attend the same course as another colleague, please indicate your colleague's name here.

Attestations*

I have read the Enrollment and Payment Policy
I consent to my submitted data being collected and stored.

By submitting your application, you consent to our storage and use of your data per our Privacy Policy and Terms & Conditions.

Course Type

Simulation Instructor Training
MOCA/Crisis Resource Management Training
Labor and Delivery Team Training

Course Application

Course Selection & Date

Application Form for Simulation Instructor Training

Application for Labor and Delivery Team Training Courses

MOCA/Crisis Resource Management Training for Practicing Anesthesiologists (ACRM) Workshops

Registrant Information

Contact Information

Billing Information

Other Information

Course Application

Course Selection & Date

Application Form for Simulation Instructor Training

Application for Labor and Delivery Team Training Courses

MOCA/Crisis Resource Management Training for Practicing Anesthesiologists (ACRM) Workshops

Registrant Information

Contact Information

Billing Information

Other Information

Course Policy

Enrollment Policy

Cancellation Policy

Payment Policy