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Trainee Registration Form
The Indo-American Cancer Association and Pallium India Certificate Course in Pain & Palliative Care
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Name of the Centre *
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Trivandrum Institute of Palliative Sciences, Thiruvananthapuram
MNJ Institute of Oncology, Hyderabad
Tata Memorial Hospital, Mumbai
Gujarat Cancer Research Institute, Ahmedabad
Cipla Palliative Care and Training center, Pune
CanSupport, New Delhi
Kasturba Medical College, Manipal, Karnataka
Name of the Trainee *
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Profession of the Trainee *
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Age of the Trainee *
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Professional qualification of the Trainee *
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Current job responsibilities of the Trainee *
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How did you hear about this course? *
Why are you doing this course? *
Please explain briefly, the reason for taking up this course and list top three goals you have in mind
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Did your department / institution/ work place encourage you to do this course? *
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I have registered for the six weeks IACA-TIPS certificate course in pain and palliative medicine/nursing. I am fully aware of the course curriculum, schedules for this course and agree to abide and complete them. I have also been explained clearly, in the language that I understand; the requirement of completing assignments, questionnaires of evaluation and feedback forms during and after the course. I understand that the responses would be analyzed and used for future publications and I give my consent for the same. *
The log-book entries, feedback forms as appendices, case reflections are to be submitted as indicated in your introduction letter.
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