LogoContinuing 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 it to the address below or fax it to the number indicated.

La Crosse Exercise and Health Program
Education Services Unit
221 Mitchell Hall
University of Wisconsin-La Crosse
La Crosse, WI 54601
Fax: 608-785-8686

Make checks payable to: La Crosse Exercise and Health Program

I WISH TO REGISTER FOR THE WORKSHOP(S) LISTED BELOW:

COMPREHENSIVE CARDIAC REHABILITATION (April 28-May 1, 2014)

  • Regular Price: $595 _____
  • AACVPR or Affiliate Member Price: $570 _____

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 and hotel information, if necessary.

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