SEE™ TET Registration Request Form

Train-the-Endoscopy-Trainer (TET) Course Registration Request Form

PLEASE NOTE: Your name will be placed on the SEE™ Program waitlist (you will not automatically be enrolled into a course). We will contact you via email to confirm enrollement.

Disclaimer: “Out-of-Province licence” must be obtained by delegate three (3) months in advance of course. Please contact your Provincial College of Physicians and Surgeons to inquire about the necessary documentation before you register for a SEE™ course being held outside of your province.

Full Name *

Prefix First Name Last Name

*

Male Female

E-mail *

Phone Number *

CAG Member *

Yes No

CAGS Member

Yes No

CSCRS Member

Yes No

Specialty *

Gastroenterology - Adult Gastroenterology - Pediatric Internal Medicine Surgery Colorectal Surgery Family Medicine

Position *

Institute / Hospital *

Number of years practising *

City *

Province *

Country *

Please select the SEE™ Centre location(s) for your course.

If you have date preferences for your course based on the SEE™ course schedules noted on the SEE™ webpage, please fill-in date (otherwise leave blank).

SEE™ Centre Location

Scheduled Date Course

Month Day Year

SEE™ Centre Location

Scheduled Date Course

Month Day Year

SEE™ Centre Location

Scheduled Date Course

Month Day Year

SEE™ Centre Location

Scheduled Date Course

Month Day Year

How did you hear about the SEE™ Program? *

Any other comments or information you would like to provide:

In submitting this application, I am agreeing that I will not, in any way, utilize, reproduce or disseminate the CAG SEE™ Program curriculum. *

Yes, I agree. No, I do not agree.