Course Request Form

Interested in bringing the Emergency Surgery Course to your institution? Complete the Course Request Form below to begin the process. This form collects essential contact details, course information, and hosting acknowledgments required to coordinate and deliver an ESC program at your site.

Course Contact Information

First Name ^* (required)

Course Director Email ^* (required)

Course Director Phone Number (required) ^* (required)

Country where course will be held: ^* (required)

List any other names and email addresses that should be listed on all communication (i.e., course coordinator, assistant, co-course director, etc.):

Contact #1 Name

Contact #1 Email

Contact #2 Name

Contact #2 Email

Course Information

ESC Course Date ^* (required)

Course Acknowledgement

ESC Acknowledgement ^* (required)

I understand that I am responsible for ordering and paying for the ES Textbooks

I understand that I am responsible for travel, hotel, and food for the course faculty

I understand that I am responsible for all costs related to venue including AV, room rental cost, and food

I understand there is a fee to host the course (€50/per registrant) and I will pay it within 30 days after receiving the invoice. I understand the textbooks will not be shipped until the fee is paid.

I understand that I am required to fill out a final report and submit it within 30 days after the course is completed

I understand that I must fill out an evaluation form on the course

Signature ^* (required)

Today's Date ^* (required)