Schedule an Event

College or Institution Name Please enter the Institution Name

Course Number (If applicable) (optional)

Please indicate if this is a new or repeat event: New Repeat Please indicate if this is a new or repeat event:

Please enter your 1st choice of date(s) Please enter your 1st choice of date(s)

2nd choice of date(s) Please enter 2nd choice of date(s)

Time of Event: AM PM All Day Please select an option

Primary Contact Name Please enter you First name and Last name

First name and Last name

Address Please enter your address

Phone Please enter your phone number

Email Please enter a valid Email

Brief Description of the Event Please brief Description of the Event

Type of Learners. For example: Med/Nursing/Vet Students, level/year or clinicians.

Total number of learners. Please enter total number of Learners to be involved

Will you require Standardized Patients? Yes No Will you require Standardized Patients?

Will you require healthcare providers? Yes No Will you require any Nurses (RN, LPN)?

Will you require Simulation Equipment? Yes No Will you require Simulation Equipment?

If yes, what kind? (optional) What kind of simulation Equipment?

Will you need Case Scenarios Developed? Yes No Discuss Will you need Case Scenarios Developed?

Will you require Digital Video recording? Yes No Will you require Digital Video recording?

Learning and Assessment Center