Referral Form Info

Please help us identify participants for the 2013-2014 Teaching of Tomorrow series. We hope to offer two tracks: Basic Track 1 for new faculty/preceptors, and Advanced Track 2 for past TOT graduates. We are seeking participants from around the Northeast from each of the primary care disciplines.

There will be two, two-day workshops. Sessions will begin Friday from approximately 10:00 a.m. to 5:00 p.m. followed by a reception and Saturday from approximately 8:00 a.m. to 4:00 p.m. We expect the dates & locations for the series to be as follows:

Workshop I: November 15-16, 2013 -- Cranwell Resort, Lenox MA
Workshop II: March 14-15, 2014 -- Hotel Northampton, Northampton MA

There will be a $2,000.00 Registration Fee which covers both workshops, hotel expenses and CME credits. Travel expenses will be the participant's responsibility.

Please complete this referral form for either yourself or colleague(s). You can submit up to 3 referrals on 1 form. If you have greater than 3 referrals, simply submit the first 3 and then open up the link again to submit more.

Thank you for your continued support and participation in this program!

* 1. Form Submitted by (Your Name):

* 2. If you are filling out this form for yourself and are interested in Track 2, please list 1 or more topic areas that you would like to see covered in the curriculum:

* 3. Referral 1 Full Name

* 4. Referral 1 Academic Affiliation

* 5. Referral 1 Discipline

* 6. Referral 1 Degree

* 7. Referral 1 Course Choice

* 8. Referral 1 Address (Street, City, State & ZIP)

* 9. Referral 1 Email