Summer 2018 Interprofessional Team Management of Pain_Development Course_2018_RegistrationForm

Application for Non-credit/Development Course Registration: Summer 2018 Session *Note: This pathway is for individuals pursuing education for personal development, who are not seeking graduate credit No transcript is generated when registered for a non-credit Development course (PHPD Masters, Certificate and non-matriculated student are not eligible to register for Non-credit/Development courses.) Course Name: Interprofessional Team Management of Pain - PREP 244 Course Directors: Alan Witkower, EdD, CGP and Daniel B Carr, MD, FABPM, FFPMANZCA(Hon) Course Dates: Blended Learning: Onsite, Face-to-Face 2-day weekend at Tufts University School of Medicine, plus synchronous online videoconferencing sessions On campus meetings: Sunday, June 3rd at – PM and Monday, June 4th at AM – PM Online synchronous meetings: videoconferencing for case discussions and team problem-solving continue, on Wednesdays, June 6, June 13, June 20 and June 27 from 6:00 to 8:00 PM EDT Successful completion of this course may be able to be applied for professional development/continuing education requirements Contact the course directors in interested in how this course might be used by a participant to meet pain education requirements by the Massachusetts Board of Registration Full Name: Last First Middle Job Title: Organization Name and URL: _ Organization Address: Street Home or Mobile Telephone Number: City Work Telephone Number: State Zip Email: Payment Information: Registration Fee: On or before May 8, 2018: $947 After May 8, 2018: $757 Please see payment options below: CHECK: Make checks payable to TRUSTEES OF TUFTS COLLEGE and mail to: Tufts University School of Medicine, Public Health and Professional Degree Programs Attn: Janice Gilkes, Director of Enrollment Services 136 Harrison Avenue Boston, MA 02111 CREDIT CARD: Please check this box if you plan to pay with a credit card: You will be contacted by the Tufts University Registrar with further information regarding credit card payment Please make sure you have listed a valid e-mail address above so that we may contact you Thank you Completed forms can be mailed to the address above, faxed to 617-636-0898 or sent by e-mail via PDF to Janice.Gilkes@tufts.edu