IMS Application.

Prefix: Mr Ms
First Name:
Last Name:
Discipline: Physician Nurse Other:
Specialties:
Title:
E-Mail Address:

Affiliation: (Choose all that apply)and Enter Name
Simulation Center:
Hospital:                  
Other:             

Address 1:
Address 2:
City:    
State: 
Zip Code:
Country:
Telephone Number:
Course Name: (Choose One)

Please Enter any other information you feel would help us in
setting up your Course;

Comprehensive Course $3875, Teaching Course $2,800, and Graduate Courses $3,400.

Enrollment and cancellation policy:
Tuition will be due two weeks after receiving your acceptance. We would appreciate you reconfirming your intention to attend by reply email at this time. When a class fills up, we start a waiting list. If you must cancel and another candidate can fill your seat, we will refund your tuition, less $100 for administration and processing. If we cannot fill your seat, we will refund half your tuition, less $100 for administration and processing.

Make Check or Money order payable to the "Center for Medical Simulation"
Send to:
Rhonda Young
Center for Medical Simulation
65 Landsdowne St.
Cambridge, MA 02139