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Arizona Telemedicine Training

Registration

Fees waived for network members and Arizona residents. Group discounts also available.

Date                                                                  Time           Price

June 10 and 11, 2009                            9:00 am        $500                    

August 12, 2009                                     9:00 am        $300

October 7 and 8, 2009                           9:00 am        $500

December 9, 2009                                  9:00 am        $300

February 10 and 11, 2010                    9:00 am        $500

April 14, 2010                                          9:00 am        $300

                                                                       

                                                                        Total: ________

 

      Tucson                or                 Phoenix
                                                                            

 

Name/Title ___________________________________________________________

Address 1 ____________________________________________________________

Address 2 ____________________________________________________________

City/State/Zip ________________________________________________________

Phone _____________________________ FAX ______________________________

email _______________________________________________________________

 

Method of Payment     Check    Visa    MasterCard

Credit Card # _________________________________________________________

Three Digit Security Code (on back) _______________

Exp. Date ________________________________  Zip code ____________________

Name as it appears on card _____________________________________________

Signature ____________________________________________________________

or

Purchase Order# ___________________________________________________

Area of Interest Specific Goals:

Area of Interest

Clinical ___________________________________________________________
Administrative _____________________________________________________
Educational _______________________________________________________
Technical _________________________________________________________

Print this page and FAX or mail completed registration form to:

Janae R. Cooley
Arizona Telemedicine Program
550 E Van Buren, Building 2
Phoenix, AZ 85004

Fax: 602-827-2118