HEART-IM Registration & Payment

Name*

First Last

Email*

Phone*

Participant information

I've already submitted my participant information with a previous tuition payment

Participant information

Emergency contact name*

First Last

Phone*

Meal Preference*

Special Requirements: Please describe any special requirements that we should know in the space above (e.g. medical conditions, wheelchair access, life-threatening allergies, etc.)

Tuition

Tuition*

Tuition payments are due by December 15 for accepted applicants.

If positions remain open after December 15 additional applications will be considered on a rolling basis until March 1, 2021. Applicants accepted after December 15, 2020 will need to make their tuition payment to AMSA within 48 hours of acceptance notification to confirm their slot.

An AMSA member - $200
Not an active member of AMSA -$225

Total

$0.00

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name