ACS ERRA Enrollment Form

2025 ACS ERRA Enrollment Form
Please submit one enrollment form for each program you are enrolling in the 2025 ACS ERRA. Even if the payor is the same, please treat dual programs as separate programs (e.g. Integrated Vascular vs. General Surgery). This form must be completed by May 30th, 2025. You will be invoiced once the form is processed.
Did your program participate in the ACS ERRA last year ?*
How did you learn about the ACS ERRA?*

ACS Clinical CongressACS websiteAPDS conferenceEmail from ACSUtilized ERRA in the pastOther
Program Enrollment

The cost per resident is $150. Only entering PGY-1 residents are eligible. No administration on 6/19 as ACS is closed.
Program Specialty, if applicable
(example: Plastic, Thoracic, Urology, Vascular; if General Surgery or not applicable, leave blank)
Program Name*
(how you want it displayed on your score reports)
Enrollment Number*
Only entering PGY-1 residents are eligible.
Total Cost (USD) = *
The cost per resident is $150.
Administration Date

MonthDayYear
No administrations on 6/19 as ACS is closed. If you do not yet know date or time, please leave blank.
Administration Time (3-Hour Window)

If you do not yet know date or time, please leave blank. Hours Minutes Minutes

AM/PM Option
Time Zone
Second Administration Date, if applicable

MonthDayYear
(No administrations on 6/19 as ACS is closed)
Second Administration Time, if applicable (3-Hour Window)

Hour Minutes

AM/PM Option
Contact Details
ACGME Number*
Street Address*
Street Address, Line Two
Room Number, Suite Number, PO Box, Department Name, Etc.
City*
State/Province*
ZIP / Postal Code*
Program Director Information
Is your Program Director new this year?*
Program Director First Name*
Program Director Last Name*
Program Director Email*
example@example.com
Program Director Phone Number*
Please enter a valid phone number.
Send the invoice to Program Director?*
Program Administrator Information
Is your Program Administrator new this year?*
Program Administrator First Name*
Program Administrator Last Name*
Program Administrator Email*
example@example.com
Program Administrator Phone Number*
Please enter a valid phone number.
Send the invoice to Program Administrator?*
Please use this space to share any additional information regarding your ERRA enrollment or administration:
Should be Empty:

2025 ACS ERRA Enrollment Form

Program Enrollment

Contact Details

Program Director Information

Program Administrator Information