Continuing Education Workshops-Workshop Registration
Name__________________________________________
(Print exactly as it should appear on your certificate.)
Job Title/Position________________/_________________
Hospital ________________________________________
Mailing Address__________________________________
_______________________________________________
City ___________________ State _____ Zip ___________
Business Phone (_____) _____- __________
Home Phone (_____) _____- __________
Fax Number (_____) _____- __________
E-mail _________________________________________
Feel free to print this form and mail to the address below:
La Crosse Exercise and Health Program
Education Services Unit
221 Mitchell Hall
University of Wisconsin-La Crosse
La Crosse, WI 54601
Make checks payable to: La Crosse Exercise and Health Program
I WISH TO REGISTER FOR THE WORKSHOP(S) LISTED BELOW:
COMPREHENSIVE REHABILITATION ($575)
April 21-25 ___
September 22-26 ___
PULMONARY REHABILITATION ($425)
October 13-15 ___
BASIC ELECTROCARDIOGRAPHY ($75)
April 20 ___
September 21 ___
If you register within 2 weeks of the workshop start date, please call 608-785-8683 to confirm space and to provide us with a number where we can fax registration materials, if necessary.
