REGISTRATION

Register today using the form below.

First Name

Last Name

Status(MD, RN, etc.)

Hospital Affiliation or Company Name

Address

City

Province/State

Postal Code

Country

Business Telephone

Cell/Mobile Phone

E-Mail Address

Date in

Date out

Number adults

Number children

Additional Comments

Enter payment amount please enter registration amount IE: 500.00 do not put a $ sign in front of the amount (calculated based on tuition fees) format for payment xxx.xx

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