workshop registration form

Please provide the following contact information:

Name:
Title:
Organization:
Address:
City:
State/Province:
ZIP/Postal Code:
Country:
Work Phone:
Fax:
E-Mail:

Program of Interest:
           Strategies for Diabetes ManagementDomestic Violence: A Primary Health Care IssueWWW for Health Professionals: 2hr Hands-On WorkshopIntroduction to PubMedInternet Essentials for Health ProfessionalsWeb Research for Health ProfessionalsEnhanced Patient Communication

What types of professionals will be attending the program?
           MD/DO
           PA
           NP
           RN/LPN/MA
           Nutritionist
           Other

How many participants from your organization are expected to attend?
          

Best Time of Offer a Workshop (first choice):
           Monday morningMonday noonMonday afternoonMonday eveningTuesday morningTuesday noonTuesday afternoonTuesday eveningWednesday morningWednesday noonWednesday afternoonWednesday eveningThursday morningThursday noonThursday afternoonThursday eveningFriday morningFriday noonFriday afternoonFriday evening

Best Time of Offer a Workshop (second choice):
           Monday morningMonday noonMonday afternoonMonday eveningTuesday morningTuesday noonTuesday afternoonTuesday eveningWednesday morningWednesday noonWednesday afternoonWednesday eveningThursday morningThursday noonThursday afternoonThursday eveningFriday morningFriday noonFriday afternoonFriday evening

Do you have space at your location for the session?
           Yes No

Do you have a TV/VCR available?
           Yes No

Is there an available phone jack in the space for the session?
           Yes No

After clicking on "Send", you will return to the workshops page.

NNHAHEC is a program of NCHC, INC.