Health Services Education registration form for CHSER

Health Services Education for Long Term Care Professionals, Assisted Living Manager Certification, Nursing Home Administrators - The Center for Health Services Education, CHSER

The Center for Health Services Education
and Research
PO Box 1654, San Marcos, TX 78667-1654

Ph.512.392.4092 * Fax.512.392.1258
Cell.512.393.1630
Email

ASSISTED LIVING MANAGEMENT ADVANCED PRACTICE REGISTRATION

Advanced Practice Seminars - Registration Options:

Fax to 512.392.1258 and if paying by check, mail payment or include credit card information.
Print this form and mail either with credit card information on the form or check payment:

Dr. Marian Upchurch
CHSER
PO Box 1654
San Marcos, TX 78667-1654

You will also need to print the certification record, complete it and mail to CHSER along with renewal fee. Renewal fee is $50.00 payable to CHSER. (this is in addition to any APS fees.)

click here for Continuing Education Record for the Assisted Living Management Certification Program

Select Program:

Day 1:	Ethics (6 hours CE) and Human Resources (2 hours CE)
Day 2:	Regulatory Update Leadership and Management (8 hours CE)
Day 3:	Strategies for Serving Residents with Dementia (8 hours CE)

Advanced Practice Seminars	$135.00 per day: $395.00 for all three
1 day (specify date): ____________	Specify Location: _______________
2 days (specify date): ___________	Specify Location: _______________
3 days (specify date): ___________	Specify Location: _______________

Participant Information:

Name	_____________________________
Address (Street)	_____________________________
Mail Add (if different)	_____________________________
City, State, Zip	_____________________________
E-mail	_____________________________
Phone	_____________________________
FAX (for registration confirmation)	_____________________________
Organization	_____________________________

Method of Payment (please check choice):

Visa MasterCard	Mailing a Check
Card Number: ________________________Expires:_________
Name on Card: __________________________
Card Billing Add (include State & Zip) ________________________State: __ Zip: ________

* Payment is required at the time of enrollment.
* Cancellation requests received up to two weeks prior to the program date will be refunded at 75% of the registration fee or full credit at another site during the calendar year.
NO REFUNDS WITHIN THE TWO WEEKS PRIOR TO PROGRAM DATE.