Registration Fee: Buy One Get Second Half Off
$250 for 1st registrant; $125 for 2nd registrant; $250 for 3rd registrant; $125 for 4th registrant

Three Ways to Register and Pay

1. Fax registration and pay by check or credit card (off-line)
Click here to access the PDF version of the registration form

2. Register on-line and pay by check
Complete the form below and click “Submit without Payment”
Mail check to:
Partners in Medical Education;
109 Brush Creek Road; Irwin, PA 15642
Note: We will invoice you if you choose this option

3. Register on-line and pay securely by credit card
Complete the form below and click “Pay On-Line”

Will you be using your Partners Telecourse Passport for this Telecourse? If yes, please select the type of Passport you are using.
*Note to Individual Passport owners. If your session balance does not cover this telecourse, we will email you an invoice for the additional sessions at a special per-session fee. Don’t have a Partners Telecourse Passport? Click here to learn more details. and continue below with your registration

Institution Information

* Institution Name * Address * City: * State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY * Zip: * Date of next site visit (Institution or Program)”     * How did you hear about this telecourse? Email flyer Fax Flyer Personal Email Colleague Other

Registrant 1

Registrant 2

* First Name: * Last Name: Degree: Title: * Dept: * Phone: Fax: * Email: # Years in GME :   Ok to share contact information Yes No   *(required for registration confirmation)

* First Name: * Last Name: Degree: Title: * Dept: * Phone: Fax: * Email: # Years in GME:   Ok to share contact information Yes No   *(required for registration confirmation)

Registrant 3

Registrant 4

* First Name: * Last Name: Degree: Title: * Dept: * Phone: Fax: * Email: # Years in GME :   Ok to share contact information Yes No   *(required for registration confirmation)

* First Name: * Last Name: Degree: Title: * Dept: * Phone: Fax: * Email: # Years in GME :   Ok to share contact information Yes No   *(required for registration confirmation)

If you have more than 4 people to register, please complete a second registration form.