Course Request Form

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)