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Telemedicine Courses Online Registration

 
*Course Selection
Two-Day Telemedicine Course, January 27 & 28, 2010 at Sacramento, CA
If attending the full course, please select the track of your choice for day two:
Clinical Operations Track, January 28, 2010
Technical Track, January 28, 2010
If you are attending just one day of the two-day course, please select from the following:
Day 1, Executive Overview, January 27, 2010
Day 2, Clinical Operations Track January 28, 2010
Day 2, Technical Track January 28, 2010
*Attendee Information
Name *First *Last  
Degree/Suffix M.D. Ph.D. R.N. L.V.N. P.A. other
Job Title  
Organization
*Mailing Address
*City
*State *Zip Code
Phone Fax
*E-Mail Address
*Social Security Number (last 4 digits only)
*Fee Information
California based organizations with not-for-profit status - $300 per person for a one-day session; $600 per person for two-day session;
California based organizations with for-profit status - $500 per person for a one-day session; $1,000 per person for two-day session;
Organizations based outside of California - $500 per person for a one-day session; $1,000 per person for two-day session
*Tuition Scholarship Information
— Scholarships are awarded on a first-come, first-serve basis and will be limited to a maximum of five individuals per organization. To qualify for a scholarship, individuals must be from organizations within California, meet one of the following criteria and provide supporting documentation with your completed application.
  • A public or nonprofit medical facility or other public facility that has been designated as a health professional shortage area (HPSA) or serves a geographic area or population group that has been designated as a HPSA or a medically underserved population as defined the Public Health Services Act.
  • An area, population or public or nonprofit medical facility that has been determined by a responsible federal or state agency (e.g. CA Office of Statewide Health Planning and Development) as having a significant need for a particular health care service that is not being adequately met by existing resources in its service area.
  • A public or nonprofit medical facility that demonstrates it serves a medically or financially underserved population that is not being adequately met by existing resources.
Check here if you will be applying for tuition scholarship from the Center for Health and Technology. Upon submitting this registration form, please visit our Tuition Scholarship Web page (www.ucdmc.ucdavis.edu/cht/services/education/scholarship.html) to obtain the Tuition Scholarship Application Form.
Payment Information
— Tuition may be paid by check, American Express, Discover, MasterCard or VISA.
— Please send your check, made payable to UC Regents, to Janice Carpenter, UC Davis Health System, Center for Health & Technology, 2300 Stockton Blvd., Suite 3300, Sacramento, CA 95817.
If paying by credit card, please phone Janice at (916) 734-1314.
— Payment must be received fifteen calendar days prior to the date of the course for guaranteed enrollment. Cancellations received in writing fifteen calendar days before the first day of the course will be refunded less a $30.00 processing fee. Refunds after that date will be considered for extenuating circumstances and are subject to a $50.00 processing fee.
Further Information
— If you need disability accommodations, please let us know:  
— If you have dietary requirements, please list details: