MOCA - ACRM Application Form

Anesthesiologist that are on staff at; BIDMC, BWH, CHB, 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:

* 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;

COURSE FEE: $1500.00

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:

Gary Rossi
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 imedialty after you receive 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 your tuition.