Education and Training Web-Based Program Sign-up

Directions: Please complete the online form below. You may also complete a printable version and then fax it to 847-270-3891.

Questions: Please contact the eLearning Administrator at 877-301-0009.

* Required Fields

* Healthcare Organization

* Contact Name

* Contact Email
email@address.com

* Contact's Department Name

* Contact's Phone
555-555-5555

Contact's Fax
555-555-5555

* Address

* City

* State

* Zip Code

Baxter Customer Number

Does your facility use a learning management system with Internet access?
Yes No

Is your facility a HealthStream customer? Yes No

To take advantage of the user management and reporting features of the site, you will need to designate an individual within your organization to serve as an administrator for the site:

Administrator's Name

Administrator's Phone
555-555-5555

Administrator's Email
email@address.com

Requested Username

Requested Password

or Cancel