Activity Request

Activity Request

We need a few details about your activity to help us get started. All applications for CME credit must be submitted 6 months before the date of the activity.
Name

First NameLast Name
Company
E-mail
example@example.com
Optional: Name of second person/staff you wish to receive e-mail notices about this program:

First NameLast Name
Optional: Second person/staff e-mail:
example@example.com
Phone Number

Area CodePhone Number
NOTICE: AS of April 1, 2026 we no longer provide credit to any program that has pharmaceutical/commercial support funding.
YesNo
Title of Activity - you CANNOT CHANGE this! *
We have a size limit on our LMS - No long titles - please.
Date of Activity*
How many speakers will you have? Please remember you will have to have a signed disclosure for EACH. Only speakers you want credit for!*
How many meeting planners will you have? Please remember you will have to have a signed disclosure for EVERYONE you list. MAX 10*
Based on your selections below we will form an agreement with costs.
CME (Physician, Physician Assistant, Nurse Practitioner, Nursing Home Administrator)Dentistry
Nursing (Kentucky Nursing)Respiratory (Kentucky)EMS (Kentucky)Certificate of Attendance
YesNo
Social Work (Kentucky Must have ALL Paperwork three months in advance to apply)Professional Counselors (KY - Must have ALL paperwork three months in advance to apply)Licensed Alcohol and Drug Counselors (KY - Must have ALL paperwork three months in advance to apply)Community Health Worker (KY -Must have ALL paperwork three months in advance to apply)
Radiology (Kentucky) Must have lectures that target Radiology - objectives must include Radiology component. Must have ALL slides for presentations two months in advance to applyPharmacy (KY - Must have ALL slides for presentations three months in advance to apply)Sonographer - Must have checked CME aboveDietitian (Kentucky) MUST have a dietitian on the planning committee - CDR credentialed RD or DTR, and provide their registration number.
Live In-PersonLive Stream (Example Zoom)Enduring Material )Regularly Scheduled Series (grand round and tumor board) For Staff - must be same staff/audience every time .
How many hours of credit are you applying for?*
Note: We DO NOT set up any Zoom presentations/conferences.
NoYes
Any specific questions you want to go over when we contact you.
Should be Empty:

Activity Request

NOTICE: AS of April 1, 2026 we no longer provide credit to any program that has pharmaceutical/commercial support funding.