UK Ampcare ESP Registration

Processed through Medicare Innovations International, Ltd.

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Registrant's Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Credentials

List Here if Other

Training Options

If you select a Hybrid + Zoom or Live/In-Person option, please select a date

Hybrid: On-Demand + Zoom Webinar

Hybrid: completion of 4-hours of pre-work required before the Zoom date.

Live/In-Person

Blended course; 4-hours online, 6-hours in-person

Phone *

Health and Care Professions Council (HCPC) Number

Relevant license to practice number for your credentials

Affiliation *

Trust, Company or Facility Name

Will you need ASHA CE Hours

You are an International Member of the American-Speech-Language-Hearing Association and will submit these CE Hours for renewal

List ASHA Number here if applicable

List Name Number

Any additional comments