Participation Request



Before submitting a participation request, make sure you have:

1. Gotten approval from the network technical contact at your facility

2. Reserved a video conferencing room at your facility

The participation request must be submitted at least 3 working days before the event is scheduled.

 Click here for information on your facility's technical contact or Contact Us

Todays Date:

EVENT INFORMATION
Facility: (Req.)
if 'other' please describe:
Event: (Req.)
if 'other' please describe:
PARTICIPANT CONTACT:
Name: (Req.)
Phone: (Req.)
Email: (Req.)
Cell#: (Opt.)
Additional Participants:
Will you be attending for CME or CECH hours? YesNo
Videoconferencing room reserved YesNo (Req.)
IT Approval YesNo (Req.)
Additional Comments:
Please send a copy of this request to: