Health Services Education for Long Term Care Professionals, Assisted Living Manager Certification, Nursing Home Administrators - The Center for Health Services Education, CHSER The Center for Health Services Education
and Research
PO Box 1654, San Marcos, TX  78667-1654

Ph.512.392.4092  *  Fax.512.392.1258
Cell.512.393.1630
Email


Registration Form: 

  1. Fax to 512.392.1258 and if paying by check, mail payment or include credit card information.

  2. Print this form and mail either with credit card information on the form or check payment:

Dr. Marian Upchurch
CHSER
PO Box 1654
San Marcos, TX 78667-1654

Select Program:  click here for schedule information>>

Sign Up for:  Price

Level I (3 days)

$395.00 + $45.00 = $440.00

Specify Location:  __________________

Date: __________

   

Level II (2 days)

$295.00

Specify Location:  __________________

Date: __________

   

Advanced Practice Series

$135.00 per day
$395.00 for 3 days

Specify Location:  __________________

1 day (specify date) _____________
2 days (specify date) ________________
3 days (specify date) ________________

Participant Information:

Name

_____________________________

Address (Street)

_____________________________

Mail Add (if different)

_____________________________

City, State, Zip

_____________________________

E-mail

_____________________________

Office Phone

_____________________________

Cell Phone

_____________________________

Home Phone

_____________________________

FAX  (for registration confirmation)

_____________________________

Organization

_____________________________

Method of Payment (please check choice):

Visa   MasterCard  MasterCard 

Mailing a Check

Card Number: ________________________Expires:_________

Name on Card: __________________________

Card Billing Add (include State & Zip) ________________________State: __ Zip: ________

* Payment is required at the time of enrollment.
* Cancellation requests received up to two weeks prior to the program date will be refunded at 75% of the registration fee or full credit at another site during the calendar year. 
NO REFUNDS WITHIN THE TWO WEEKS PRIOR TO PROGRAM DATE.

12/04/2009 Update * Copyright 2002 * All Rights Reserved * The Center for Health Services Education & Research
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