IPEG Course Endorsement Application

Courses must be directed or coordinated by an IPEG member, or have at least one IPEG member as its primary faculty.
The course location must be equipped with the adequate facilities for laboratory and classroom instruction. The center must also have a good record of animal care.
The course topic must be endoscopy or minimally invasive surgery.
Institutions within the United States should be ACCME accredited and offer CME credits. lf not, an explanation must be provided. Those courses offered outside the U.S. should meet the equivalent national guidelines for their country.
The Course Director must ensure that ACCME and FDA (or equivalent) guidelines on disclosure of conflict of interest are enforced.
All brochures and faculty lists much be submitted to the IPEG office as part of the review. lf the review shows a course below standards and if deficiencies are not corrected following notification by IPEG, the Training Center endorsement will be suspended.
Courses must also meet criteria for definition, objectives, qualification of faculty and participants, site, curriculum, components, and endorsement documentation.

Tier 1

Brand Endorsement
$500 USD

Upon Approval of the Application, IPEG Agrees to:

Send no more than 3 mass emails on behalf of the course
Publish advertising in the Advance, Final Program, and app if approved a minimum of 90 days prior to the Annual Meeting
Feature the course on the Endorsed Courses page on the IPEG Website
Share the course on Facebook and Twitter, as requested by the applicant
Allow permission to utilize the IPEG Logo and endorsement statement on Course Materials

Tier 2

Promotional Endorsement
$250 USD

Upon Approval of the Application, IPEG Agrees:

Send no more than 2 mass emails on behalf of the course
Publish advertising in the Advance and Final Program, if approved a minimum of 90 days prior to the Annual Meeting
Feature the course on the Related Meetings page on the IPEG Website
Share the course on Facebook and Twitter, as requested by the applicant

Which tier of endorsement would you like to purchase?*
Endorsement is valid until the end of the course. This amount will be returned if endorsement is not granted, less a $100 administrative processing fee.
- Tier 1 - Brand Endorsement
- Tier 2 - Promotional Endorsement
Contact Information
Institution*
Institution Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Course Administrator*
First Last
Course Administrator Phone
Course Administrator Email*
Course Director*
First Last
Course Director Phone
Course Director Email

Will other surgeons direct other specific courses? lf yes, list all names and indicate if they are IPEG Members

(As a reminder: Course must be directed or coordinated by a IPEG member, or have as it's primary faculty at least one IPEG member)

Name	IPEG Member Y/N

Course Title*
Graphics and Mass Email Content
Please upload any graphics or marketing material.
We do not accept PDF documents, so please upload any text in a word document or supply an html file, if you have your own email template.
Drop files here or

Accepted file types: jpg, gif, png, doc, docx, txt, html, Max. file size: 64 MB, Max. files: 5.
Please upload any relevant documentation.
You may also email documentation to [email protected]
Drop files here or

Max. file size: 512 MB.
Additional Course Information
Course Types*
Check all that apply.
- Lecture Only
- Lecture & Hands On
- Other
Average Length of Course (in hours)*
Didactic Portion Hands On Portion
Will CME credits be issued for course?*
If yes, by which organization/institution?*
If no, please explain why.*
Please give a brief description of the classroom facilities, including number of rooms available for lectures, approximate number of seats in each room, etc.*
Please indicate if the facility has an animate laboratory.*
If relevant, please give a brief description of the labaratory facilities, including the number of tables in the lab, veterinarians or lab techs on staff, etc.

Total
$0.00
Payment Type*
- I will pay by Credit Card
- I will pay by check
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Address for Credit Card*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Make check payable to:

IPEG
Attn: Jacqueline Narváez
11300 W. Olympic Blvd. Suite 600
Los Angeles, CA 90064

International Pediatric Endosurgery Group