OHE - Organization of Healthcare Educators

OHE REGISTRATION FORM

Implementing Patient Family Centered Care: Patients and Families as Partners,
Advisors and Educators
Saturday April 14, 2012 8:30 am - 12:00 pm

Download PDF Brochure

We do accept PayPal

STEP 1: Please fill out the OHE Registration Form as completely as possible. Before submitting please print this form for your records.

STEP 2: After submitting you will be sent to the next page for instructions regarding payment methods.

* required field

First Name:*

Last Name:*

Credentials:*

Degree

License

Certification

Title:

License #

Name Tag:*

“PRINT name and credentials as you would like them listed on your name tag”

Facility:*

Home Address:*

Apt #:

City:*

State:*

Zip Code:*

Please provide us with at least one phone number:

Home Phone:

Which is your preferred phone number?
(If providing more than one number)

Home
Mobile
Work

Cell Phone:

Work Phone:

Fax:

E-Mail:*

Confirm E-Mail:*

Student:

Yes
No

If answered Yes:

School

Degree Program

Estimated Graduation Date (ex: MM/YY)

NNSDO Member?

Yes
No

Comments:

REGISTRATION INSTRUCTIONS:

If you will be paying by Personal or Corporate Check, please print this form by using the print button below or print function from your browser (or by using Ctrl +P).

Please include print out with your Personal or Corporate Check.
Your registration will not be complete until we have received your payment and print out.

Once you have printed this form, click on “Submit Form” to go to the next page to see the payment requirements.

Notice: Please be aware that due to the fees associated with the convenience of online payment, the mail-in cost structure listed in the brochure is different than the online fees. Each online option has an associated $5.00 processing fee attached.

If you would like to pay by mail, print your online registration and send with payment to:
O.H.E. c/o Ms. Nicole Olsen-Garcia
5008 Stevely Avenue
Lakewood, CA 90713

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