Request New Group Setup

To request that a new group or organization be set up, follow the instructions below. After the group is approved and set up, this will allow students or faculty from that organization to sign up under that group membership.

If you are a member of an existing group, please go to the Student Registration page. If you do not see your group listed there, please contact your group representative, or use the Tech Support link in the tabbed navigation at the top of this page to send us an inquiry.

Please fill in the Organization information and the organization's Group Administrator information below to request a new user group for the Geriatric Self-Assessment. When complete, use the “Request New Group” button at the bottom to submit the form, and it will then be sent to the Concepts in Geriatric Care program administrator for processing. Fields marked with a red asterisk are required.
Part 1 - Group or Organization Information
Group Name: *
Group Abbreviation (if any)
Maximum Number of Students *

Part 2 - Required Designated Administrator Information
A designated administrator must be set up for each group. This administrator will then be able to manage the users within that group, including adding and removing user accounts, and viewing individual student information. This administrator is automatically granted access to all available modules.
Name Information
First: * M.I.:
Last: *
Address Information
Work Address: * Apt.:
City: * State or
Province: *
Postal Code: * Country: *
Contact Information
Home Phone:  Work Phone: *
Fax: E-mail
Address: *
User Name (6-16 letters or numbers, no spaces, case sensitive): *
Password (6-16 letters or numbers, no spaces, case sensitive): *