Registration Form

Emergency Medicine Oral Board Review
April 6 - 10, 2008
September 7 - 11, 2008

(required fields are marked with an * )

Last FIVE Digits of Social Security Number* 

Register for:	SpringFall
First Name*
Last Name*
Suffix (Jr., Sr., etc)
Prefer to be called
Company / Institutional Affiliation
Specialty
E-mail Address*
Degree:	MDDO
Course materials are sent by UPS or FedEx, which do not accept PO Box addresses.
Home Address*
(required in order to receive the course materials)
City*
State*
Zip Code*
Cell Phone*
Fax

If someone you know is attending as well, please provide name so we may assign appropriate teams:

Special Dietary Needs: *
I require vegetarian lunch
I have no special dietary needs.

Registration Fee: $1,795

Method of Payment: *

Employer Check Personal Check MasterCard Visa Discover

Make checks payable to Emergency Medicine Services of SI, PC

(If check is being mailed, please also provide credit card information)

To be completed by credit card users:

Credit Card No.
Expiration Date

For your protection, no information, including
credit card numbers, are stored on this server at any time.

 

No registration will be accepted without payment.

All applicants should try to register 4 weeks prior to the start date to each course to ensure available housing.  However, registrations will be accepted up until 2 weeks before the course starts pending housing and course availability.

Space cannot be guaranteed in the program for registrations we receive after this date. Exceptions may be granted on a case by case basis. Contact Marie Vislocky 718-226-9151 or mvislocky@siuh.edu.

All cancellations must be in writing. Tuition for cancellations postmarked one month prior to the start date of the course will be completely refunded. Cancellations made between 2 and 4 weeks prior to the start date will be assessed a $200 administrative fee before being returned. A $400 late cancelation fee will be assessed for applicants who cancel during the two weeks preceding the start of the course.  No refunds will be made after the course has been started.

Although we have never once had to cancel this course, SIUH reserves the right to cancel this program if sufficient registrations are not received. In the case of cancellation, the department will fully refund registration fees.