ADLS Course Registration Form

Use this form to register for the ADLS Course offered Monday and Tuesday, Sept. 22 and 23, 2008, at the MACIE Training Center, 1615 Springfield St., Dayton, OH 45403. The course meets from 8 a.m. to 5 p.m. on Monday and from 9 a.m. to 5 p.m. on Tuesday. The course fee is $400 for physicians, $250 for other healthcare personnel and $100 for full-time undergraduate and graduate students in an accredited college or university. For more information, please visit our ADLS information page or contact Julia Smith at (937) 775-1320.

First Name:
Last Name:
Profession/Status:
Employer/School:
Employer/School Address:
Employer/School City:
Employer/School State:
Employer/School Zip:
Home Address:
Home City:
Home State:
Home Zip:
E-mail:
Home Phone:
Work Phone:
Comments:
   
Thank You!

For NDLS and AHA Course information, contact:
Dan Kirkpatrick, R.N., M.S.N.
Assistant Director, Workforce Development
(937) 775-1320
Fax: (937) 775-1329
daniel.kirkpatrick@wright.edu