Name:

Address

Name of Workshop 1

Name of Workshop 2

Name of Workshop 3

Method of Payment

Check one:

Check/money order payable to
           Hospital Education in the amount of .......... $ __________

MasterCard or VISA
           in the amount of ............................................. $ __________

Account Number _____________________________________________
Expiration Date ______________________________________________
Name of Card _______________________________________________
Signature as it Appears on Card _________________________________

Check or money order should be made payable to Hospital Education. Mail or fax (credit card only) entire registration form to:

Registration
Box 3883
Duke University Medical Center
Durham, NC 27710

Fax: (919)-681-6251