Registration Form

Online registration is not available. Please use your computer to complete this form. Print and mail or fax the completed form to the GEPN office (see below).


Name:
Highest Degree:
Job Title:
Nursing Specialty:
In which role do you spend most of your time?
Minority
Minority Type:

If you are faculty, please list the school in which you are employed.
School:
School Address:
School City:
School State:
School Zip Code:
School Country:
The school is classified as

Preferred Mailing Address:		 School Organization Home
Organization Name:
Street Address:
City:
State:
Zip Code:
Country:
E-mail:
Daytime Phone Number:
Fax number:

Please indicate any GEPN educational offerings you have previously completed (select all that apply):
Genetics Summer Institute
Web-Based Genetics Institute
Genetic Testing 7-Week CE Course
Family History Skill-Based Module



Offering #1:  Web-Based Genetics Institute - January 23 - May 29, 2009, $1200 (one-week of 'online' orientation begins January 19th).
Additional costs: required textbooks. Remember to include your check, money order, credit card information or purchase order number with your registration.
Offering #2:  Applying Genomics in Nursing Practice - September 26 - October 31, 2008, $400 (orientation begins September 22nd).
Remember to include your check, money order, credit card information or purchase order number with your registration.
Offering #3:  Applying Genomics in Nursing Practice - March 20 - April 24, 2009, $400 (orientation begins March 16th).
Remember to include your check, money order, credit card information or purchase order number with your registration.


PAYMENT METHODS (Children's Hospital Medical Center's Tax ID#: 31-0833936)
Check or Money Order - Make payable to Children's Hospital Medical Center
Purchase Order #:  
Credit Card: MC VISA AmEx
Card Number:  
Expiration Date:  
Cardholder's Printed Name:  
Cardholder's Signature:  


Reminder: Please print the completed registration form and mail or fax it to the GEPN Office.


Mail to:
Jo Ann Monday, Program Coordinator
Genetics Program for Nursing Faculty
Division of Human Genetics, ML - 4006
3333 Burnet Avenue
Cincinnati, OH 45229-3039
Phone: 513-636-0123
Toll-free phone: 800-344-2462 extension 60123
Fax: 513-636-0124
Email: gepn@cchmc.org