John Ingram Leadership Institute Program Application

Please Select Specific Leadership Program - You may apply for more than one program on a single application.*

2024 Leadership Lab (January 10- July 25)2024 Leadership Immersion (2 Live meetings, June 21-23 & July 26-27)2025 Leadership Lab (January 8- July 24)2025 Leadership Immersion (2 Live meetings, June 20-22 & July 25-26)

If your first choice is full, please indicate if you want to be added to the waiting list or to be enrolled in the same class for the next available date. (Mark only one)*

Add me to the waiting list for the class I originally chose.Register me for the same class for the next available date.

TMA Membership Requirement for Participation

Ninety percent of program costs are underwritten by generous contributions from The Physicians Foundation and TMA. Participation is limited to TMA member physicians only. If you are not a member, your application will be PENDING until you join: tnmed.org/join

Full Name*

Medical Degree*

MDDO

What name should your peers use to address you? (ex. nickname or name other than your full first name)

Preferred Email Address (primary point of contact)*

Cell Phone Number*

TMA Member*

YesNo

Specialty*

City of Practice*

Region

County Medical Society*

Medical Specialty Society Memberships

Please provide a brief description of what you hope to gain from participation in program: *

Meeting Logistics

Please answer the questions in this section to help us in our planning.You will be asked about food and lodging accommodations: For meetings held in Nashville (Live Lab meetings and 2nd weekend of Immersion program), lunch and snacks will be provided during meeting days, with a private celebration dinner on the final evening of each program in July (Thursday evening of Lab presentations and Friday evening of July Immersion dates). Hotel rooms will be offered for individuals traveling from outside of the local area. For individuals registering for the Immersion Program, our opening Immersion retreat is held in Monteagle, TN. All participants will have rooms reserved for both Friday and Saturday evening. The retreat runs from 8:00 AM Friday morning - 1:00 PM Sunday afternoon. Our schedule for the retreat is full, with group activities planned from breakfast through dinner. Often we are asked if spouses or other family members may attend the retreat. This retreat is about you as physicians, and we recommend your attending alone. Also, the facility we use has a policy of no children under the age of 10, as the facility is not set up for small ones.

Do you have any food allergies or dietary restrictions we should be aware of when planning meals throughout the program? If yes, please list your needs or restrictions specifically so that we may do our best to accommodate (for example, instead of listing "no beef" - please be specific in listing which types of meat you will eat or if all meat is off limits*

Lodging

Please note, cancellation of hotel rooms less than 72 hour notice will result in you being billed for the rate of the room.

Will you need hotel accommodations for meetings held in Nashville?*

YesNo

For the Monteagle Immersion retreat, will you need an additional reservation for the Thursday evening prior to our Friday morning start?*

YesNoMaybe

I acknowledge the hotel cancellation policy*

YesNo

Tuition and Sponsorship

Tuition for each course is $1,000. The Leadership Institute is a program of the Tennessee Foundation for Quality Patient Healthcare (TFQPH). Financial underwriting is provided through a generous grant from the Physicians Foundation. Additional funding for staff and administration is provided by Tennessee Medical Association. Tuition bridges the last 10-12% of course expenses. Materials, speaker fees, continuing education credits, lodging and meals are included. Travel to and from event program venues is the responsibility of each participating physician.

Cancellation Policy

We keep a wait-list for individuals who wish to take these courses, however, due to multi-day schedules for these programs, we need to know as soon as possible if you will be unable to attend the course you are registered to attend.

Registrants needing to withdraw from either program up to 90-days prior to the event start date will receive a full refund, less a $150 administrative fee. Registrants wishing to move their course registration to the same program the next available course date, will have their full tuition credited toward the new course registration.

No refunds will be given for cancellations 90-days or less prior to course start date. If we are able to fill a late vacated seat in the class from our waitlist, we will refund tuition less the $150 administrative fee.

Tuition sponsoring organization or Individual?*

Email to be used for invoice*

example@example.com

If sponsored, please indicate:*

FullPartialN/A

If partially sponsored, please indicate amount:

I acknowledge the Leadership program's cancellation policy:*

YesNo