Registration Form

Family Engagement Collaborative

Start Date: November 1, 2019

Payment Due: July 20, 2019

One submission and $2,500 fee per ICU

Register ICUs Hospital Name:
(no acronyms please)

Associated Health System:
Hospital Address:
ICU Type: Adult Pediatric

Surgical
Medical/Surgical Combined
Trauma
Medical
Cardiac
Burn
Geriatric
Neuro
Other:


Number of Beds:
Contact Person Contact Name:

Contact E-Mail:

Contact Title:

Contact Credentials:

Contact Address:

Contact Phone Number:

SCCM Member:
Yes I am a Member I am not a Member I am unsure if I am a Member
Disclaimer

Please contact SCCM Customer Service by e-mail at support@sccm.org or by phone at +1 847 827-6888, Monday through Friday between 8:00 AM and 5:00 PM Central Time with questions. Applications close June 30 2019 and Payment is due by July 20 2019.

Cancellations must by submitted in writing. All cancellations are subject to a $75 nonrefundable processing fee and must be postmarked before July 20 2019, to be eligible for a refund. Cancellations postmarked after this date will not be refunded. Please allow four weeks to proces refunds.