Request for Clinical Skills Workshop Support

Request for Clinical Skills Workshop Support

Name*

Email*

Phone Number*

Position

Institution*

Faculty Sponsor Name (If not provided above)

Terms & Conditions

• ACR appreciates receiving applications to the Program. It reserves the right to accept applications from some, but not all, medical school or affiliated programs that apply. • The materials that ACR provides to Program participants are informational resources only. ACR is not liable for any act or omission by a medical school or affiliated program related to using the materials. • Additional terms and conditions are defined in the specific tier information. On behalf of my medical school program, I understand and agree to the terms and conditions listed on the application as a condition of participation in this American College of Radiology Tiered Workshop Program.

Checking the box indicates acknowledgement and acceptance of the above terms.

Tier URL will be added here

Which Tier Level are you interested in?

Select or enter value

Program or Institution URL

Program or Institution Mission / Vision

Please provide three possible dates for your workshop.

If you selected Tier 2 or 3, please indicate the other institutions that you are partnering with.

Partner institutions are those who are actively participating in the development and execution of the workshop. This is not a list of institutions who will be invited to attend the event.

How many students are you expecting?

Contact if not listed above

Do you have a Radiology Interest Group at your institution?

Select or enter value

Do you plan on developing one in the future?

Select or enter value

Brief description of why you want to host a Radiology Workshop.

Please explain why ACR would be a good partner for your workshop.

Has ACR sponsored/funded your organization in the past? If so, please list the date(s) & program name?

How would you promote this partnership?

Send me a copy of my responses

Privacy Notice|Report Abuse