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Registration Form

Chief Resident Immersion Training (CRIT) Program
in the Care of Older Adults

When:  Friday evening, June 3  Sunday afternoon, June 5, 2016

Where:  Resort & Conference Center at Hyannis, Cape Cod, MA

Registration forms will be accepted on a rolling basis until Friday, April 15, 2016.

When you have completed the application form, click on the "Submit" button below, so your information will be forwarded to the Geriatrics section.

Once registered, you will receive additional information on the CRIT Program schedule. All registrants are expected to stay for the entire duration of the program.

CRIT Program attendees must provide their own transportation, which will be reimbursed after the program takes place. Additional details will be provided after your registration is complete.

*   Indicates required field
 
* Full Name:
  Title:
  Gender:     
  Home Address:
  City:
  State:
  Zip:
  BMC Address:
* E-mail Address:
* Pager #:
  Office Phone:
* Home / Cell phone:
* What is your medical speciality (subspeciality,
if applicable) or professional discipline?
* How many people (including yourself) will
be attending?
 
* If you know anyone else attending, do you wish to share a room with him/her?
 
  Other comments regarding accommodation:
Note: To request reasonable accommodation for a disability,
please notify Nilsa Carrasquillo (Nilsa.Carrasquillo@bmc.org), in writing,
at least two weeks prior to the conference.
 
  Dietary restrictions:
  Additional questions/concerns:
 
THE INTERNET IS NOT SECURE ─ WE HIGHLY RECOMMEND AND ADVISE YOU NOT TO PROVIDE ANY CONFIDENTIAL OR SENSITIVE INFORMATION OVER THE INTERNET. IF YOU CHOOSE TO DO SO, IT IS AT YOUR OWN RISK. ANY UNLAWFUL OR CRIMANAL CONTENT PROVIDED, WILL BE SUBJECT TO LAW ENFORCEMENT REVIEW.
 
 
 

For additional information, please contact:

Boston Medical Center
Geriatrics Section
ATTN: Nilsa Carrasquillo
88 E. Newton Street
Robinson 2700
Boston, MA 02118


Call: 617.638.6112
Fax: 617.638.8387
Email: Nilsa.Carrasquillo@bmc.org


NOTE: The CRIT Program in the Care of Older Adults is funded by BMC.


Errors With Submission:

Appointments

Call: 617.414.4639
Fax: 617.414.4094

Boston Medical Center
Geriatrics Clinic
Shapiro Center
725 Albany Street
9th Floor, Suite 9A
Boston, MA 02118

Refer a Patient

Call: 617.414.4639
Fax: 617.414.4094

Home Care & Nursing Home Program Referrals & Information

Call: 617.638.6100
Fax: 617.638.6179

Administration Office

Boston Medical Center
Section of Geriatrics
88 East Newton Street
Robinson 2
Boston, MA 02118-2393
Call: 617.638.8383
Fax: 617.638.8387

Education Program

Call: 617. 638.6112
Fax: 617.638.6152

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