Please complete the following information and click the Send button at the bottom to send the form securely. If you have any questions or need assistance, please call us at (865) 269-4616. We also have an offline PDF version of this form, if you prefer to print and fax back to us. Click Here for our PDF Form. Fax back to (865) 269-4613 or you can edit the form, save and email back to firstname.lastname@example.org Name of Facility: (required): Contact Person (required): Number of Participants (required): Physical Address (required): City (required): State (required): Zip (required): Phone # of Contact Person (required): Alt. Phone #: Email Address of Contact Person (required): Name and Address of Training Location (required): Mailing Address Of Facility (if different from physical address): Nearby Lodging (required): Lodging Address (required): Lodging Phone # (required): # Of Miles From Training Location: Closest Airport: Distance to Lodging: INCLUDES: 10 Hours of Moderate Sedation Training Manual Subliminal Bio-Rhythmic Music CD for Intra-op Listening Certification is Valid for 2 Years 1-year complimentary membership in the American Association of Moderate Sedation Nurses (AAMSN) • Each application requires a copy of professional license and current ACLS or PALS to be submitted at sign in. • Certification is available to RNs, MDs and PAs • LPN's may take the workshop for CE Credits only and Receive a Certificate of Training Facility Conference Room Information: 1. Max number of seating: 2. Amphitheater: ---YesNo 3. Tables: ---YesNo ---RectangleRound 4. Whiteboard: ---YesNo 5. LCD Projector: ---YesNo 6. Lapel Microphone: ---YesNo 7. Computer: ---YesNo Describe type of audio visual your facility provides: Facility required to send to Healthy Visions the following one week (7 days) prior to class start date unless contacted by Healthy Visions: ---Yes List of registered participants with Name and RN# ---Yes Copy of each registered participants ACLS and/or PALS ---Yes Copy of your facilities current Sedation Policy This class is open only to those who pre-register. Certification Exam offered only to those who complete the entire onsite course. We Come to your facility: Minimum up to 20 attendees 1-20 = $4,000 plus expenses. There is a $200 tuition fee for each participant over the 20 participant minimum payment. See example below: Contract is based on the number of attendees submitted by registration closing date which is 10 days prior to Sedation Certification Course date. Example a course date of May 25 will have a course close date of 4:00 PM ET on May 15. Any participants added after the closing date incurs an additional $50 fee over the usual $200 participation fee for a total of $250 for any participants added after the closing date. Classes may be canceled without penalty if done so within 10 days of contract agreement. Classes canceled 10 business days or later from contract date incur a cancelation fee of $500. A rescheduling fee may be imposed dependent on instructor travel arrangements. Number 21 plus Amount 1-20 $4,000 $200 per attendee over 20 21 $4,200 30 $6,000 35 $7,000 40 $8,000 50 $10,000 75 $15,000 100 $20,000 Contract participant numbers and payment are due by the closing date of the course.