Telehealth Conference Registration

Telehealth Legal Update:
New & Emerging Legal Risks
SECURE ONLINE REGISTRATION FORM
You may also type on form online, print & fax or mail to:

Carol M. Stock & Associates
P.O. Box 31114
Seattle, WA 98103
(206) 789-0909 Fax/Phone
email:

For protection of your credit card information all data is encrypted.

I am registering for: Minneapolis, Minnesota - September 24, 2009

Your First Name: Your Last Name:

Degrees:

Additional Names:
(If registering for a group of 2 or more people)

Agency Name:

Contact Phone #:
(Include area code)

Street Address:

City: State: Zip:

E-Mail Address:
(No personal identifiable information, including email address, is shared with third parties).

Fax #:

Check the box at left if you agree for your name and agency to appear on the attendee list (No telephone numbers or email addresses will be listed).

Nursing License Number:

Primary Position (check one)
RN Staff Nurse
RN Manager
LPN/LVN
Physician
Other Please specify

Your Practice Setting (check one)
Ambulatory Clinic / Physician Office
Hospital
Call Center
Other Please specify

Your Practice Area of Specialization (check one)
Family Practice
Internal Medicine
Pediatrics
OB/GYN
Cardiology
Gastroenterology
Orthopedics
Call Center
Other Please specify

Cost: $175 per person. Tuition includes continental breakfast, beverage service, three hour conference, and a one hour DVD on Telehealth Legal Issues.

Pre-registration is required.

Please check here if you need an ADA accommodation. We will contact you.
.

Three Payment Options:

Option 1:
Credit Card Payment Online

Please include total for all registrants.

ABOUT SSL CERTIFICATES

Amount $

Credit Card

Card Number

Expiration

Cardholder's Name

Cardholder's Billing Address (If different from Registration Address)

Signature (If you are printing out form): _________________________________________

Option 2:
Credit Card Payment By Fax, or Mail, or Phone
If you do not wish to submit your credit card information online, please type the registration and credit card information on the above form online and then print out & fax to (206) 789-0909 or mail to
Carol M. Stock & Associates, P.O. Box 31114 Seattle WA 98103.

Option 3:
Payment By Check or Money Order by Mail
Check or Money Order Enclosed, Payable to Carol M. Stock & Associates, P.O. Box 31114 Seattle WA 98103
Please type the registration information on the above form online and then print out & mail, with payment enclosed, to Carol M. Stock & Associates, P.O. Box 31114 Seattle WA 98103.

Registration confirmation: Confirmation of your registration for the seminar will be sent by email, if email address provided. Otherwise, confirmation will not be sent.

Refund/Cancellation Policy: Cancellations will be accepted without penalty seven (7) business days prior to the event. A $50 administration fee will apply to all refunds. Registrants who fail to attend the program or cancel after the above time frame shall be liable for the entire conference fee. No charge will be made for substitutions.

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