2023 Tinnitus Care Provider Certificate Program Registration Form

The Tinnitus Care Provider Certificate Program is being held virtually, November 17-19, 2023. The workshop is held live online, 10:00 AM to 5:00 PM ET each day. Use this form to sign up! Contact us at education@ihsinfo.org if you have any questions.

IMPORTANT: If you use the title, “Tinnitus Care Provider” you must also state “Holding a Certificate from the International Hearing Society.” This certificate title does not replace your job title. Certificate holders must check with their own state/provincial licensing agencies for rules, regulations and scope of practice regarding providing tinnitus care. The Tinnitus Care Provider Certificate is neither a certification nor a license to practice. Certificate holders remain bound by the scope of practice and licensure/registration requirements set forth by their governing body. Read Full Policy
Personal Information
Name*

First NameLast NameCredentials (ACA, BC-HIS...)
IHS Membership*

IHS Memberl am not an IHS member but would like to joinI am not an IHS member
What is your IHS Member ID Number? (If unknown, type "N/A")*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
example@example.com
Phone Number*

Area CodePhone Number
Which title best describes you?*

Hearing aid specialistAudiologistOwner/President/CEOTrainee/Student/ApprenticeMarketingAccount/Sales RepresentativeOperationsENTOffice StaffProfessor/EducatorOther
Company*
Which of the following best describes your work environment?*

Private Practice/ClinicRetail (i.e., Costco)FranchiseManufacturer-owned RetailEducational InstitutionManufacturerHospital/Medical ClinicOther
Do you fit devices from more than one manufacturer?*

YesNo
What is the highest academic degree you have earned?*

High School Diploma or GEDAssociate's degree in Applied ScienceAssociate's degree in ArtsAssociate's degree in ScienceBachelor's degreeMaster's degree in ArtsMaster's degree in ScienceMaster's degree in AudiologyPhDAuDOther
How did you hear about the Tinnitus Care Provider Certificate Program?*

A friend or colleagueAn email from IHSPrint advertisementAt an eventSocial media (i.e. Facebook, Twitter, LinkedIn)Other online sourceOther
What are your reasons for attending this program?*
Continuing Education Information
License State/Province*
What is your license number?*
Date license was issued*
Last 4 digits of Social Security Number*
If you need AAA CEUs, please provide your AAA Member #
Payment Information
Registration Information:
- The registration fee includes the three-day workshop, the participant guide, Dr. Tyler's book (Tinnitus Treatment: Clinical Protocols), participant resources, and 16 CE credits.
- The $300 assessment fee is paid separately when making the examination appointment. The assessment must be taken within 30 days of the completion of the workshop.
Cancellation and Refund Policy:
- To be valid, IHS must receive notification of your cancellation in writing. A refund, minus a $50 processing fee, will be granted for cancellation requests received on or before October 31, 2023. Beginning November 1, 2023, no refunds will be given. However, a substitute may attend.
Accommodations Information:
- If you require special accommodations to fully participate, please contact IHS at 734-522-7200 or education@ihsinfo.org.

Tinnitus Care Provider Program Registration Fees (note: IHS Membership will be verified upon registration.)*

IHS Member Price

$1,695.00

Join IHS & Register - Save $ Now! (US only)

$2,020.00

Join IHS & Register - Save $ Now! (Canada & International only)

$1,830.00

IHS Non-Member Price

$2,225.00

Enter coupon

Total

$0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

By checking the below box, I assert that I have read and agree to adhere to the policies of the Tinnitus Care Provider Certificate Program.
I agree to the Tinnitus Care Provider Certificate Program policies*

I agree
Upon successful completion of the program, I agree that IHS may list my name publicly in a directory on an IHS webpage and through various IHS publications congratulating new certificate holders.*

YesNo
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Personal Information

Continuing Education Information

Payment Information