Training Course Registration Please enable JavaScript in your browser to complete this form.Dates of Training you are interested in: *Location of Training *Name *FirstLastAddressCityState---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip CodeDate of BirthAgeCell PhoneHome PhoneEmail *Pregnancy Center NameDirector's NameNurse ManagerOrganization AddressOrganization PhoneOrganization EmailHighest Level of DegreeType of DegreeYear of DegreeRegristry or Nurses Licence #Are you registered in more than one field?YesNoIf yes, please list here:Have you had previous ultrasound training?YesNoWhat organization provided your training?What year did you recieve your training?Did you recieve a certificate of compentency?YesNoApproximately how many scans do you preform a month?Have you recieved a refresher course?YesNoWhat year?Do you have a sonographer available to assist you in providing ultrasound?YesNoDo you have a licenced nurse of physician that has been certified to provide limited ultrasounds?YesNoWhat is the manufacture and year of your ultrasound system?Are you looking for a new or used system?NewUsedI would like to share the following with a participantA hotel roomAn "Uber"A rental carCommentSubmit
