Application Form

Open Course Dates

* Required

* Course Name / Date:

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:

ENTER Your Address:

* Address 1:

Address 2:

* City:

* State:

* Zip Code:

* Country:

* Telephone Number:

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

IMS COURSE FEES:
Comprehensive Instructor Course $3,875
Comprehensive Instructor Course with OB Track $3,875
DASH Training Webinar, 4 1/2 Hours $350
CRM and MOCA for Anesthsiologists Course $1500
Graduate Courses including webinars and 3 days at CMS $3,400.

PAYMENT:
The Center for Medical Simulation accepts payments by credit card, money order or check.

To pay by credit card, please contact Rhonda Young at reyoung@partners.org.
Payment by money order or check should be made out to "Center for Medical Simulation" and sent to:

Rhonda Young
Center for Medical Simulation
65 Landsdowne St.
Cambridge, MA 02139

Enrollment and cancellation policy:
You will be informed of your acceptance to the selected course above by email. Please reconfirm your intention to attend by replying to the acceptance email.

Tuition is due two weeks after you have received your acceptance email. Payment details are provided below.

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, you will forfeit half your tuition we will refund the remaining half.