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EPECEducation For Physicians/Providers on End-of-Life Care REGISTRATION FORM Please indicate Date/Location registering for __________ BRANSON, MO June 20-21 (F/S) __________ ROLLA, MO October 25-26 __________ SPRINGFIELD August 16-17 (S/Su) __________ KANSAS CITY December 6-7 (Please PRINT) Name____________________________________________________________________________ Place of Employment__________________________________ Dept/Specialty________________ WORK Address____________________________________________________________________ City______________________________State_________________Zip________________________ Work Phone______________________________E-MAIL_________________________________ Work Fax________________________________ Discipline: ______MD _______DO _____LNHA _____RN _____LPN _____Social Work _____Pastoral Care OTHER (Please Indicate)________________________ HOME Address____________________________________________________________________ City________________________________State_____________________Zip_________________ Home / Cell Phone_____________________________
COURSE IS COMPLIMENTARY - However, we ask for a voluntary donation of $25 - $50 to help our non-profit cover costs of printing the EPEC Manual and CD. Thank you! Manual, Power Point CD, Education Credit & Meals provided (Space Fills Up Quickly ~ Register early to reserve your space!) Fax Registration to Community Alliance for Compassionate Care FAX NUMBER (417-865-5725) For More Info Call: 417.865-4501(o)
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