1 Start 2 Preview 3 Complete Thank you for your participation in the Advanced AS Curriculum pilot. We are confident that your feedback, paired with your knowledge and expertise will help to prove this a valuable resource for all ID fellows wishing to lead a stewardship program. Please note: After you have completed and submitted this form, you will receive an email confirmation within 24-48 hrs with a unique coupon code for your institution to access the course. We ask that you please not share this code with outside institutions, since this is limited to a few programs. In the boxes below, please provide the name of your Institution, full name, and e-mail address of all fellows/trainees and faculty that you are registering the Advanced AS Curriculum. Name of Institution * Please spell out your Institution name Program Type (Pediatric or Adult ID) * Please select your program type. Pediatric Adult ID Other Program Type (Pediatric or Adult ID) Other Program Director/Faculty Advisor * Enter first name, last name Program Director/ Faculty Advisor E-mail address * Are you registering Faculty? * Yes No Faculty Registration Faculty Member 1 Enter first name, last name Faculty Member 1 E-mail address Faculty Member 2 Enter first name, last name Faculty Member 2 E-mail address Faculty Member 3 Enter first name, last name Faculty Member 3 E-mail address Faculty Member 4 Enter first name, last name Faculty Member 4 E-mail address Faculty Member 5 Enter first name, last name Faculty Member 5 E-mail address Still need to add more faculty? Yes No Additional Faculty Registration Faculty Member 6 Enter first name, last name Faculty Member 6 E-mail address Faculty Member 7 Enter first name, last name Faculty Member 7 E-mail address Faculty Member 8 Enter first name, last name Faculty Member 8 E-mail address Faculty Member 9 Enter first name, last name Faculty Member 9 E-mail address Faculty Member 10 Enter first name, last name Faculty Member 10 E-mail address Are you registering fellows/trainees? * Yes No Fellow/Trainee Registration Fellow/Trainee 1 * Enter first name, last name Fellow/Trainee 1 E-mail Address * Fellow/Trainee 2 Enter first name, last name Fellow/Trainee 2 E-mail Address Fellow/Trainee 3 Enter first name, last name Fellow/Trainee 3 E-mail Address Fellow/Trainee 4 Enter first name, last name Fellow/Trainee 4 E-mail Address Fellow/Trainee 5 Enter first name, last name Fellow/Trainee 5 E-mail Address Fellow/Trainee 6 Enter first name, last name Fellow/Trainee 6 E-mail Address Fellow/Trainee 7 Enter first name, last name Fellow/Trainee 7 E-mail Address Fellow/Trainee 8 Enter first name, last name Fellow/Trainee 8 E-mail Address Fellow/Trainee 9 Enter first name, last name Fellow/Trainee 9 E-mail Address Fellow/Trainee 10 Enter first name, last name Fellow/Trainee 10 E-mail Address Still need to add more fellows/trainees? Yes No Additional Fellow/Trainee Registration Fellow/Trainee 11 Enter first name, last name Fellow/Trainee 11 E-mail Address Fellow/Trainee 12 Enter first name, last name Fellow/Trainee 12 E-mail Address Fellow/Trainee 13 Enter first name, last name Fellow/Trainee 13 E-mail Address Fellow/Trainee 14 Enter first name, last name Fellow/Trainee 14 E-mail Address Fellow/Trainee 15 Enter first name, last name Fellow/Trainee 15 E-mail Address If you need more fields for faculty or fellows/trainees than the form allows, please e-mail academy@idsociety.org, for more information. Leave this field blank
