EPEC

Education For Physicians/Providers on End-of-Life Care

REGISTRATION FORM

Please indicate Date/Location registering for     

_________________________________________________

(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)