Executive Education Program Registration Form

Please complete the form below to register for the Brandeis Health Leadership Program June 1-6, 2026. Upon receipt of your form, the program will reach out to you to confirm your registration and provide next steps. If you have questions, please email HellerExecEd@brandeis.edu.

First Name (Given Name)

Last Name (Surname)

Birthdate

Email Address

Phone Number

Mailing Address

Country

Street

City

Region

Postal Code

Medical Specialty

Current Organization/Institution

Current Position/Title

Total Years of Experience

Please indicate if you are receiving sponsorship from any of the following organizations:

No Sponsorship / Private Pay

American College of Surgeons Scholarship

Society of Thoracic Surgeons Scholarship

Society of American Gastrointestinal and Endoscopic Surgeons Scholarship

American Society for Metabolic and Bariatric Surgery Scholarship

Other

Other Sponsor:

Please complete your program registration by clicking on the "submit" button below. Upon receipt of your form, the program will reach out to you to confirm your registration and provide next steps.