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)
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