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

Registration Form:

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

Select Program: click here for schedule information>>

Sign Up for:	Price
Level I (3 days)	$395.00 + $35.00 = $430.00
Specify Location: __________________	Date: __________

Level II (2 days)	$295.00
Specify Location: __________________	Date: __________

Advanced Practice Seminars	$135.00 per day $395.00 for 3 days
Specify Location: __________________
1 day (specify date) _____________ 2 days (specify date) ________________ 3 days (specify date) ________________

Participant Information:

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

Method of Payment (please check choice):

Visa MasterCard 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.