Registration Form: MedEd Conference Certificate Program

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All conference attendees can participate in the certificate program.

The Three Step Process for participating and earning your Certificate of Achievement —

Step 1: Register here so that we can track your participation.

Step 2: Attend five MedEd Certificate Workshops over three years during the IME Conference. To receive credit for each workshop you must submit the evaluation and feedback form online or provided in the session. Please make sure to enter your name and learning points.

Step 3: Complete an online story form about how you have changed your practice as a teacher, leader, mentor, or scholar based on your participation in two of the five workshops attended. The link to submit your stories will be sent to you after you complete your fifth workshop.

Please complete all items below:

First Name *

Last Name *

Email Address *

Cell Phone Number *

Health Profession or Role in Health Professions Education *

Institution *

Personal or professional goal for participation in the Certificate program (one sentence) *

MAILING ADDRESS FOR YOUR CERTIFICATE —

Street Address *

City, State, Zip *

Submit

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