Mountain Emergency Medicine Registration Form

𝟮𝟬𝟮𝟭 𝗠𝗢𝗨𝗡𝗧𝗔𝗜𝗡 𝗘𝗠𝗘𝗥𝗚𝗘𝗡𝗖𝗬 𝗠𝗘𝗗𝗜𝗖𝗜𝗡𝗘 𝗖𝗢𝗡𝗙𝗘𝗥𝗘𝗡𝗖𝗘 𝗩𝗶𝗿𝘁𝘂𝗮𝗹 𝗔𝗰𝘁𝗶𝘃𝗶𝘁𝘆 𝗔𝗽𝗿𝗶𝗹 𝟯𝟬 - 𝗠𝗮𝘆 𝟮, 𝟮𝟬𝟮𝟭 𝑷𝒍𝒆𝒂𝒔𝒆 𝒑𝒍𝒂𝒏 𝒐𝒏 𝒄𝒐𝒎𝒑𝒍𝒆𝒕𝒊𝒏𝒈 𝒕𝒉𝒆 𝒇𝒐𝒓𝒎 𝒊𝒏 𝒊𝒕𝒔 𝒆𝒏𝒕𝒊𝒓𝒆𝒕𝒚. 𝑻𝒉𝒊𝒔 𝒔𝒊𝒕𝒆 𝒄𝒂𝒏𝒏𝒐𝒕 𝒔𝒂𝒗𝒆 𝒚𝒐𝒖𝒓 𝒊𝒏𝒇𝒐𝒓𝒎𝒂𝒕𝒊𝒐𝒏 𝒇𝒐𝒓 𝒄𝒐𝒎𝒑𝒍𝒆𝒕𝒊𝒐𝒏 𝒂𝒕 𝒂 𝒍𝒂𝒕𝒆𝒓 𝒅𝒂𝒕𝒆. 𝗣𝗿𝗶𝗼𝗿 𝘁𝗼 𝗦𝘁𝗮𝗿𝘁𝗶𝗻𝗴 𝘁𝗵𝗶𝘀 𝗙𝗼𝗿𝗺: Complete your UNM Tuition Remission paperwork (remember proper signatures are REQUIRED), complete your UNM PR and make a copy of your check, you will be required to upload a copy of these documents at the end of this form. If you are a Medical Student proof of status IS REQUIRED. You will be required to upload a copy of your current class schedule showing you are a full time student. *Students will not receive professional credit. 𝗖𝗔𝗡𝗖𝗘𝗟𝗟𝗔𝗧𝗜𝗢𝗡: If you cannot attend, UNM CPL will refund tuition, less a $40.00 administrative fee provided it is received in writing on or before {April 23, 2021}. No refunds will be issued after this date or for non-attendance. Conferences are subject to cancellation. In the event this conference is cancelled, UNM CPL is not responsible for any computer/device equipment rental or other costs incurred by participants. By completing this form, you do hereby give the UNM Health Sciences Center, the UNM Department of Emergency Medicine/International Mountain Medicine Center and the Office for Continuous Professional Learning and its designates the irrevocable right to use photographs of me, and or my property, my name (or any fictional name), picture, portrait, or photograph in all forms and media and in all manners, including composite or modified representations, for advertising, trade or any other lawful purposes, without further compensation to me, and I waive any right to inspect or approve the finished version(s), including written copy that may be created and appear in connection therewith. All negatives, positives, and digital files, together with the prints shall constitute The University of New Mexico’s property, solely and completely.

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*

Select

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?*

Home

Business

Phone Number*

Email Address*

Zoom Login Email Address

We will be using Zoom as the conference platform. If your Zoom login is different than the email address above please provide that email address.

Registration Fees

Registration Code - Regular*

Select

Optional Workshops

Workshops are limited to 20 people per workshop; ALL workshops are located in the Albuquerque area, exact locations will be announced closer to the conference.

Optional Workshop - Friday, April 30th (1:00 - 5:00 PM)

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Optional Workshop - Saturday, May 1 (1:00 - 5:00 PM)

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Other Information

What type of CME credit do you need?*

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Payment Method

Payment Method*

Please select your payment method below. If you are using another payment option (Free registration, Scholarship, etc...) please select other and explain.

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If you selected other payment method please explain*

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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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 a student please upload your current fulltime student schedule here. *This is a required field and you will not be able to finish this form unless you upload something. If you are unable to upload the necessary information listed above please contact us at HSC-CPL@salud.unm.edu or 505-272-3942 for assistance.

Drag and drop files here or

𝗢𝗻𝗰𝗲 𝘆𝗼𝘂 𝗵𝗮𝘃𝗲 𝘀𝘂𝗯𝗺𝗶𝘁𝘁𝗲𝗱 𝘁𝗵𝗶𝘀 𝗳𝗼𝗿𝗺 𝘆𝗼𝘂 𝘄𝗶𝗹𝗹 𝗯𝗲 𝗮𝘂𝘁𝗼𝗺𝗮𝘁𝗶𝗰𝗮𝗹𝗹𝘆 𝗱𝗶𝗿𝗲𝗰𝘁𝗲𝗱 𝘁𝗼 𝗼𝘂𝗿 𝗧𝗼𝘂𝗰𝗵𝗡𝗲𝘁 𝗽𝗮𝘆𝗺𝗲𝗻𝘁 𝗽𝗼𝗿𝘁𝗮𝗹. If you are paying with a Credit Card you MUST complete your payment in this portal. If you are not paying with a credit card your registration form is complete after you hit the submit button below and you can exit the TouchNet payment Portal you are redirected to. *𝒀𝒐𝒖𝒓 𝒄𝒐𝒏𝒇𝒆𝒓𝒆𝒏𝒄𝒆 𝒓𝒆𝒈𝒊𝒔𝒕𝒓𝒂𝒕𝒊𝒐𝒏 𝒊𝒔 𝒏𝒐𝒕 𝒄𝒐𝒎𝒑𝒍𝒆𝒕𝒆 𝒖𝒏𝒕𝒊𝒍 𝒘𝒆 𝒉𝒂𝒗𝒆 𝒓𝒆𝒄𝒆𝒊𝒗𝒆𝒅 𝒚𝒐𝒖𝒓 𝒑𝒂𝒚𝒎𝒆𝒏𝒕 𝒎𝒆𝒕𝒉𝒐𝒅.

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