Event Intake Form
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1.
Full Name
(Required.)
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2.
Cell Phone
(Required.)
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3.
Email
(Required.)
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4.
Your Province/State of Practice
(Required.)
*
5.
Emergency Contact Name
(Required.)
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6.
Emergency Contact Cell Phone
(Required.)
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7.
Do you have any dietary restrictions
(Required.)
None
Vegan
Vegetarian
Celiac
Gluten Intolerance
Lactose Intolerance
Other (please specify)
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8.
SMUC respectfully uses photos for marketing and training. If a photo of you is taken, may we use it?
(Required.)
Yes
No
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9.
SMUC respectfully shares names/emails with our sponsor, Pendopharm, and the companies that generously provide the ultrasound machines that we use. May we share yours?
(Required.)
Yes
No
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10.
Tell us about you! What is your current specialty/main practice type?
(Required.)
Emergency/Urgent Care
Family Medicine
Naturopathic Physician
Orthopaedic Surgeon
Sport Medicine
Other (please specify)
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11.
Do you have access to an ultrasound machine?
(Required.)
Yes, I own one
Yes, I share one
No, but I'm working on it
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12.
If you have a machine: We provide all machines necessary for courses, but you are welcome to bring your own to practice with. Will you be bringing your own machine?
(Required.)
No
Yes (which machine are you bringing?)
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13.
Select your Bootcamp level:
(Required.)
Registered for Level 1 or SMU Workshop
Registered for Level 2
Registered for Level 3