REGISTRATION INFORMATION

McGinley Symposium Continuing Education Courses

Courses begin Monday, March 12, 2012 Class size is limited

NOTE: You will not be enrolled in the course until your completed registration form and payment has been received.

Registration Fee: $35.00 per course
If you have any questions, please contact 412-396-5203 or
FAX: 412-396-5360

Registration and Payment Deadline: Monday, February 27, 2012
Payment must be received prior to the beginning of the course.

I am registering for the following (check one or both):

Immigrant Health, Sr. Rosemary Donley, PhD ($35)

Transcultural Nursing, Dr. Rich Zoucha ($35)

Pay by Credit Card:
Click here to pay

Pay by Check, Money Order, or Traveler’s Check:
Make payable to Duquesne University School of Nursing.

Mail to: OR Send via Secure Fax to:

McGinley Symposium 412-396-5360
Attn: Alyssa Kramer
Duquesne University School of Nursing
600 Forbes Avenue
Pittsburgh, PA 15282

*Successful completion of each course provides 5 Continuing Education Credits*

HOW TO USE THIS FORM:

Highlight the text in the gray area and type your answers. Click on check boxes to indicate your choice. When completed, save a copy to your computer, print and sign a copy for submission with payment.

REGISTRATION FORM

McGinley Symposium Continuing Education Course

Name: Type name

Home Address: Type address

City: Type city State: Zip: Type zipcode

Phone: Type phone Birth Date: (mo/day/year)

Email Address: Type email

SSN#: Type #

You may call in your SSN# to Alyssa at 412-396-5203

Employer: Type name Job Title: Type name

Area of Expertise (please select one):

Hospital Government
Academia Community
Public Health Other (If other, please list: Type)

City: Type city State:

Gender: Female Male

Race: American Indian or Alaska Native Native Hawaiian or Other Pacific Islander
Asian/Pacific Islander White
Black or African-American

Ethnicity: Not Hispanic or Latino Hispanic or Latino

COPYRIGHT INFORMATION

By signing below, you indicate that you accept these terms:

Each student’s, instructor’s and/or presenter’s work and correspondence is copyright property and
cannot be duplicated, copied, or posted on another website, or otherwise used without the original author’s permission.

Discussion board postings, announcements, presentations and other information contained within the course are private and cannot be duplicated, copied, forwarded, or communicated to anyone else without the original author’s permission.

Signature: Date:

By checking this box, I am providing my electronic signature approving all the information entered above. (Please enter name and date on signature and date lines above).