Workshop registration

To register for the workshop, please print the form below and mail it to the address indicated or fax it to 608.785.8686. 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.

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 _________________________________________

MAILING ADDRESS:

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

WORKSHOP PAYMENT:

COMPREHENSIVE CARDIAC REHABILITATION

  • Regular Price: $625 _____
  • AACVPR or Affiliate Member Price: $600 _____

Please make your check payable to the La Crosse Exercise and Health Program and mail it to:

Cashier's Office
University of Wisconsin-La Crosse
121 Graff Main Hall
1725 State Street
La Crosse, WI 54601