CCNC Opioid SPARC Registration

Thank you for your interest in participating in CCNC's Opioid SPARC ECHO
To reserve your space, please fill out the information below.

First Name *

Last Name *

Organization/ Practice Location *

Location Phone Number

Title/Credentials *

Participants Phone Number *

Participants Email Address *

Practice Location Address 1 *

Practice Location Address 2

City *

State *

Zip *

County

Include my contact information on lists distributed to other attendees. *

Yes

Name of any Additional Staff:

Title/Credentials:

Email Address

Name of any Additional Staff:

Title/Credentials:

Email Address

Name of any Additional Staff:

Title/Credentials:

Email Address

Name of any Additional Staff:

Title/Credentials:

Email Address

These sessions are case driven and we strongly encourage all participants to present a patient at a session. Submission and scheduling of presentations will be handled by the ECHO coordinator. There is no minimum or maximum number of sessions that must be attended. The sessions are conducted using Zoom, a video-conferencing platform. The Zoom Platform is provided without charge to the primary care practices. The participants will require a desktop, laptop, tablet or phone with a camera and microphone with internet access. Participants can join by phone but it is recommended to join by video conference. *

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