Multidisciplinary Simulation Center - CAST Pre-Application Form

Education Institute Simulation and Advanced
Skills Center

CAST Pre-Application Form

Name:

Email Address:

Phone Number:

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Information about the clinic/hospital at which you work

Name of clinic/hospital:

Street:

City:

State:

Zipcode:

Training Background

Which program are you interested in?:

Which Pathway are you interested in?:

When and where did you complete your training?:

When and where did you complete your fellowship training? In what field?:

Please list all laparoscopic procedures that you have done.:

What type and how many cases have you done?:

What do you hope to gain from this program? (Please be specific.):

When would you like to start this program? (Please note that due to our lengthy application process, we will need a minimum of 12 weeks before your training can begin):

How long would you like to train (1-8 weeks)?:

How did you hear about this program?:

Simulation & Advance Skills Login

Why Register

CAST Pre-Application Form

Information about the clinic/hospital at which you work

Training Background