Workshop registration
A page within La Crosse Exercise and Health
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