SEE™ CSI Registration Request Form

Endoscopic Polypectomy Improvement 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 enrollment.

Full Name *

Prefix First Name Last Name

*

Female Male

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 *

I have attended (check all that apply) *

SEE™ Colonoscopy Skills Improvement (CSI) course SEE™ Train-the-Endoscopy-Trainer (TET) course None of the above

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

If you have a date preference(s) for your course based on the SEE™ Program Course Schedule listed on the SEE™ webpage, please fill-in date(s), otherwise leave blank.

Simulation Centre Location *

Scheduled Date Course

Month Day Year

Simulation Centre Location

Scheduled Date Course

Month Day Year

Simulation Centre Location

Scheduled Date Course

Month Day Year

Simulation Centre Location

Scheduled Date Course

Month Day Year

Simulation 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.