PRIME Ethics Course for Physicians Registration Form

Return to PRIM~E Home Page

PRIM~E Registration Form : 2013

Note: Print this entire form. All 3 parts of this form must be filled out in ink and mailed with a deposit or payment (check or credit card) to the office listed below for the Registration to be accepted. NOTE: You are not registered until the registration is confirmed.

PART 1

First Name_____________________ Last Name__________________________

Degree _____________ Specialty______________________________________

Phone # (day) ______________________ (evening) _______________________

(Fax)______________________ (E-mail) ________________________________

Mailing Address (H) (B) ______________________________________________

City_______________________ State________ Zip Code _____________

How did you find out about PRIM-E...?

_____ Mandated by licensing board or other credentialing agency

_____ Other (Please explain) _________________________________________

Name of Licensing Board or Referring Agency: ___________________________

Contact Person and Title:____________________________________________

Address__________________________________________________________

City ___________________________ State _______ Zip Code____________

PART 2

I wish to register for the following session: ______________________________________

Please call (973) 972-4267 (or 1-800-227-4852) to check course availability. Attendance is limited and courses fill up quickly. Registration must be done by mail OR FAX to 973.972.7128 and is not complete until the registrant receives confirmation of the registration.

Course Dates:	Course Status:	Registration Deadline:
May 3-5, 2013	Course Concluded
August 23-25, 2013	Course Open for Advance Registration	August 14, 2013
October	Dates to be Determined
November	Dates to be Determined

Note: If the course you would like to attend is closed, please call (973) 972-4267 or 1-800-227-4852 to see if another course is scheduled. A minimum registration number is required but additional courses may be scheduled.

Method of Payment:

Registration Fee: $1,250 This must be paid in full three weeks before the start of the course. A non-refundable deposit of $300 is required upon submission of a completed enrollment form. The tuition fee including deposit is non-transferable. The course enrollment is limited and early registration is recommended. Enrollment will be accepted on a first come, first served basis. The tuition fee includes all teaching and reading materials as well as refreshment breaks and lunch on Saturday. Travel, other meals, and hotel expenses are the responsibility of the participant. The registration fee, minus the $300 deposit, is refundable if a written request is received three weeks before the start of the course. No refunds will be granted thereafter. A $50 administrative fee will be assessed for checks returned due to insufficient funds. NOTE: The REQUIRED READINGS packet will not be sent out until the full course fee of $1,250.00 has been paid.

_____ Check Enclosed payable to: UMDNJ-CCOE

_____MasterCard _____Visa

Card #____________________________Exp. Date_________Security Code_______

Amount $___________ Name on Card__________________________________

Signature________________________________________________________

Mail to: UMDNJ-Continuing Education, P.O. Box 1709, Newark, NJ 07101-1709
Or, Fax form to 973.972.7128.
***You MUST receive confirmation of your enrollment before your registration is final.***

If you are physically challenged and wish to discuss provisions that make your learning environment more effective, please contact Michael Santoro at (973) 972-7141.

PART 3

Dates/Location The PRIM~E... Program is scheduled to be offered at the Hilton Garden Inn, 500 Promenade Boulevard, Bridgewater, New Jersey. A block of rooms has been reserved at a special rate of $99 which includes a full American breakfast for one or two persons. The facility includes an indoor pool, whirlpool and fitness center. The hotel is quite new and is very nicely furnished. All rooms have a small refrigerator (no mini-bar); there are built-in hair dryers in each bathroom. For hotel reservations, call the hotel directly at (732) 271-9030 and mention that you are with the UMDNJ or PRIM~E group. This will guarantee that you get our negotiated corporate rate and the included full American breakfast. The dress code for the weekend is casual, comfortable. The atmosphere is friendly and non-judgemental.

Required Readings Required readings are provided well in advance of the course and two simple written assignments must be completed in advance and brought to the first session. A third written assignment must be completed at the end of the course. Details for these assignments will be provided after your registration is received.

Upon enrollment in the PRIM~E... program, it is understood that:

1. If the enrollee has entered into a consent agreement or adjudication order with the licensing board, signing this form will constitute permission for the Director of the course to request a copy of that consent agreement or adjudication order from the appropriate licensing board or agency ; Signing this form also gives permission for the Director of the course to provide an assessment of the enrollee's participation in the course to the referring licensing board or agency;

2. Participants must attend all sessions, participate in the discussions, and complete all written assignments in order for the faculty to provide an assessment to the appropriate licensing board.

3. This assessment will include: (a) certification of participation; (b) a copy of the final written assignment with faculty commentary; (c) an overall opinion of the participants capacities for ethical reasoning and insight demonstrated during the entire PRIM~E... course.

4. This assessment of the participants work in PRIM-E... will contribute to the information reviewed by the licensing board and may be a necessary--but is not a sufficient--condition for resolving the participants dispute with the board.

I understand these terms and conditions of the PRIM~E... program and hereby agree to abide by them and provide authorization for the faculty to assess my participation and to divulge the assessment to the licensing board that has jurisdiction.

Signed: _________________________________________Date:_________________

All 3 parts of this Registration Form must be completed in order for registration to be accepted. Mail the completed form and your deposit/payment check (made out to UMDNJ-CCOE) to:

PRIM~E Course Registrar
UMDNJ-Continuing Education
P.O. Box 1709
Newark, NJ 07101-1709