Event Request

Please submit at a minimum 45-60 days in advance of your anticipated program.

All requests for virtual events/programs (online course, webinar, regional conference) are subject to IPEG leadership review and approval. Submission of the request does not automatically grant permission to host an IPEG branded event. Please allow 4 weeks for processing. IPEG staff will get back to you with either approval or additional information if we need some additional info.

Event Submission Request Form

Name of the Event/ Program Title*
Program Type*
- Webinar
- Online Course
- Regional Conference
- Multi-day Programming
Target Region*
- United States
- Latin America
- Europe
- Middle East
- Asia
- Global
Proposed Program Date*
MM slash DD slash YYYY
Program Time and Duration*
Specify time zone; i.e. Pacific Time (Los Angeles). Duration; i.e. 60 minutes
Language (if requesting other than English)
List preferred language to run the program
Program Organizers*
Sponsoring Institution
Contact Information - Email*
Contact Information - Phone*
Regional Representative
- Matt Clifton & Samir Pandya (North America)
- Miguel Guelfand & Carolina Milan (Latin America)
- Mahmoud ElFiky (Middle East)
- Sabine Zundel (Europe)
- Go Miyano (Asia/Australia)
Propose collaboration to Host with specific Region or other Society
ALERT! Only upon approval can the use of the IPEG logo and promotion be made.
CME Credit Hours*
How many CME Credit Hours (if proposing)
Please enter a number from 0 to 20.
Cost for each Participant
List proposed fee structure; i.e. IPEG member and/or non-member fees
Program Description*
Learning Objectives*
List 2-5 objectives. By the end of the course, participants will be able to:
Target Audience*
Specify audience you want to reach: number of IPEG members, non-members, or specific demographics if applicable:
Proposed Topics & Faculty/Presenters*
Topic Presenter Full Name Presenter Email

If you have more than 6 presenters, submit additional info as an attachment.
Proposed Moderator*
Full Name Email address
Program Structure & Agenda*
Add as much of details as available
Upload additional files for consideration (full program, images)
Accepted file types: jpg, gif, png, pdf, doc, Max. file size: 512 MB.

International Pediatric Endosurgery Group

Event Request

Please submit at a minimum 45-60 days in advance of your anticipated program.

Event Submission Request Form

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Translation

Topic	Presenter Full Name	Presenter Email

Full Name	Email address