Taos Writing & Wellness Retreat for Health Professionals Registration Form

Disclosure Form

Dear Speaker, Planning committee member or Program Chair.

You do NOT have to register.

The only form you need to complete is the disclosure form. We will send you the link to the disclosure form shortly.

Please exit this form. Thank you!

If you have any questions, comments or concerns please reach us at: hsc-cpl@salud.unm.edu.

Unfortunately we have reached capacity!

All retreat spots have been filled at this time. If you would like to be added to the waitlist please complete the form below. If another spot opens up we will notify the waitlist in the order the forms have been received. Please plan on completing the form in its entirety. This site cannot save your information for completion at a later date.

There are TWO scholarship opportunities available. This is not the site or process to apply for a scholarship. Please click here for scholarship details.

If you wish to be on the waitlist, please check the box.

Contact Information

First Name*

Last Name*

Credentials (i.e. MD, RN, PA, etc.)*

Provide all of your credentials. If medical student, list Medical Student.

Specialty*

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If OTHER, please provide Specialty*

Company/Institution*

Professional Job Title*

Street Address*

City*

State*

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Zip Code*

What type of address is this?*

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Phone Number*

Email Address*

Registration Fees

Registration Code - Early Bird*

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Other Information

How did you hear about this event?*

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if OTHER, please provide*

I would like to have my name, phone number and email included on the list of attendees provided at the meeting.*

Yes

No

What type of CME credit do you need?*

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Please provide your dietary needs*

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If OTHER, please provide dietary need

Are you interested in carpooling with other participants to Taos?*

If you select YES we will provide your name and email address to other interested carpoolers.

Yes

No

Do you plan to bring a Spouse or Companion?*

Yes

No

Please provide the first and last name of your Spouse/Companion*

How many nights will your Spouse/Companion Stay?*

Do you and your spouse/companion prefer one or two beds?*

One Bed

Two Beds

Will your Spouse/Companion be attending Meditation & Wellness for $75?*

Yes

No

Will your Spouse/Companion be attending the Harwood Museum with you on Wednesday afternoon?*

Yes

No

Is your Spouse/Companion a UNM employee?*

Yes

No

Please provide your Spouse/Companion dietary needs?*

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If OTHER, please provide dietary need*

Payment Method

Payment Method*

Please select your payment method below. If you are using another payment option please select OTHER and explain.

UNM Tuition Remission will cover up to $1,652.52 of your course tuition (If you are eligible and have not used any of your summer tuition already). The remaining balance will be due by July 14, 2023. You will receive an email once your Tuition Remission has been processed regarding paying the remaining balance.

If you are paying the $760 deposit, your remaining balance will be due by July 14, 2023. You will receive an email with instructions for paying the remaining balance.

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If you selected other payment method please explain*

Please enter the amount you'd like to use:*

What is your UNM Banner ID?*

Session*

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Employment Status*

Faculty/Staff

Retiree

Work Number*

Phone

Signature (Full Name)*

By electronically signing this document, I agree the following information I provided above is complete and accurate.

TR Date*

Employee Certification

Please check the following statements, to indicate you acknowledge each.

Information regarding Tuition Rates and the Taxability of Tuition Remission my be viewed at: http://bursar.unm.edu/index.html

I acknowledge that I have reviewed UAP 3700, “Education Benefits” and certify this request for Tuition Remission Benefit is within the maximum allowable benefit per semester as provided in the Policy.*

I understand that I am responsible to repay all costs that exceed the maximum allowable benefit.*

I acknowledge the University will bill me for any excess tuition costs that have been paid. If the bill is not paid, UNM may collect any excess through payroll deductions*

I acknowledge that the amount of tuition benefits for certain courses are considered taxable under current published IRS regulations. I understand that any taxable tuition benefit I receive will be added to my wages as taxable income and will be subject to income tax withholding.*

Additionally, I understand that if the amount of tuition benefits I receive during the calendar year exceeds the published IRS maximum amount, the amount in excess of the IRS maximum will be added to my wages as taxable income and will be subject to income tax withholding.*

Credit Card Type*

Once you have submitted this form you will be automatically directed to our TouchNet payment portal. Please enter your payment information to complete your registration. If you do not complete the payment page your conference registration is incomplete. You will receive an email from TouchNet with your payment receipt once payment is received.

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How will you submit your Tuition Remission Form?

TR Form: https://hr.unm.edu/docs/benefits/tuition-remission-form.pdf

I will upload my form now with the appropriate signatures required.

I will email CPL at HSC-CPL@salud.unm.edu, my completed Tuition Remission form.

File Upload*

*Your conference registration is not complete until we have received your payment method.

If you are paying by check, a copy of the check MUST be uploaded here. Checks MUST be received by UNM CPL within 5 business days of completing this registration site. Please make checks payable to: UNM CPL 1 University of New Mexico MSC09 5370 Albuquerque, NM 87131-0001

If you are paying by UNM PR, a copy of the PR MUST be uploaded here.

If you are using UNM Tuition Remission, remember proper signatures are REQUIRED before uploading the completed form here.

If you are unable to upload the necessary information listed above please contact us at HSC-CPL@salud.unm.edu or 505-272-5166 for assistance.

Drag and drop files here or

I understand that my registration is NOT complete until I email my signed Tuition Remission Form*

*Your conference registration is not complete until we have received your payment method.

Once you receive your an email confirmation, notifying you have been moved out of the waitlist, we will begin the process on your payment method.

Click Send me a copy of my responses below for a copy of your answers and as confirmation of your submission.