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Distance Learning

Event Registration Form

Current Event: Healthcare anywhere: the benefits of telehealth and mobile or fixed remote patient monitoring.

This form is for event registration only.  If you are not participating in person, and in order to participate via videoconferencing you need to register and certify your videoconferencing site prior to event registration.

Step 1:

Today's Date:
Action:    New  Change  Cancel        

                  If Change/Cancel, provide registration ID: 

Step 2:

If Previously registered

Organization Name:

Organization Site ID (videoconferencing site ID):

Participant Name  
If not previously registered

Company Name: 

Purchase Order Number:

Phone No.: (including area code)

Fax No.:     (including area code)

Select Credit Card:

Credit Card No: 

Credit Card Information:

Holder's Name:

Billing Address:

City:          

State:          Zip:

Country: 

Step 3:

EVENT INFORMATION:

Number of Participants:

Name(s) of Participants:

 

Event Start Date:

Start Time: : EST      End Time: : EST

 

Event End Date:

Start Time: : EST      End Time: : EST

Event Charges:  Separate           Bundled with videoconferencing charges

Registration Deadline: September 16, 2002 (A registration fee will apply if not registered by 5:00 PM EST September  16 2002).

Fee Per Site: $US 3,000.00 (for up to 15 participants), or

Fee Per Participant: $US 300.00

Please note that videoconferencing charges are extra and as described in our Dial-Out bridging charges.

videoconferencing participants need to make sure their site is up by 8:30 AM EST.

NOTES OR SPECIAL INSTRUCTIONS:

 

 

     

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