Center for Professional Health

Maintaining Proper Boundaries Enrollment Form (to print out and fax)

2010 Maintaining Proper Boundaries
Sponsored by Vanderbilt School of Medicine and the Center for Professional Health.
Vanderbilt School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical Education for physicians.
The cost is $2450 (includes continental breakfast, lunches, and CME fees). A deposit of $1225 is required to confirm a space in the course. Please make checks payable to VMC. The balance may be paid at the course. 
Target Audience Physicians and other health professionals interested in increasing knowledge of State and Federal regulations regarding appropriate professional boundaries.
Please complete form and mail or fax (615.936.0676) to the CPH. You may also register on our website: www.mc.vanderbilt.edu/cphEach course is limited to 12 participants. Please contact us to confirm availability. Your registration confirmation will be sent by mail.
SPECIALTY: ____________________________
PHONE: ____________________________
FAX:    ____________________________
E-MAIL: ____________________________
REFERRED BY:____________________________
2010 COURSE DATES: (Please select)
      January 20-22                              
       April 14-16
       June 9-11
       August 11-13
       October 20-22
        December 8-10
A continental breakfast and box lunch will be provided daily. If you have special dietary requirements, please let us know. ______________________________
The daily course schedule (subject to change), goals, and objectives are available on our website.
Designation of Credit Vanderbilt School of Medicine designates this educational activity for a maximum of 22.25 AMA PRA Category 1 Credits ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Faculty Disclosure It is the policy of Vanderbilt School of Medicine to require disclosure of financial relationships from individuals in a position to control the content of a CME activity; to identify and resolve conflicts of interest related to those relationships; and to make disclosure information available to the audience prior to the CME activity.  Presenters are required to disclose discussions of unlabeled/unapproved uses of drugs or devices during their presentations.
All course directors, planners, and speakers indicated no financial relationships to disclose.
Americans with Disabilities Act It is the policy of Vanderbilt School of Medicine and the Center for Professional Health not to discriminate against any person on the basis of disabilities. If you feel you need services or auxiliary aids mentioned in this act in order to fully participate in this continuing education activity, please speak with Diana Phillips or Marine V. Ghulyan at 615-936-0678.
Cancellation Policy: If you must cancel your registration, The CPH will refund your registration fee, less $195.00, provided you notify us 15 days prior to the course. No refunds will be made after that time. Exceptions will be made for justifiable emergencies. Registration may be transferred to another course date. In the event of cancellation or rescheduling of this CME activity due to unforeseen circumstances, Vanderbilt University will refund registration fees in full. Vanderbilt University is not responsible for non-transferable, non-refundable airline tickets or hotel accommodations purchased in connection with attendance at this CME activity.
Course Faculty
William Swiggart, M.S., L.P.C./MHSP
Assistant in Medicine, Vanderbilt Department of Medicine
Co-Director, Vanderbilt Center for Professional Health
Ginger Manley, MSN, RN, CS
Clinical Professor of Nursing, Vanderbilt University School of Nursing
Associate in Psychiatry in the Department of Psychiatry at Vanderbilt University Medical School.
Vanderbilt Center for Professional Health (CPH)
1107 Oxford House · Nashville TN 37232-4300

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