Please provide us with your registration information:

Organization:

Street Address:

City/State/Zip:

Phone#: * Required

E-mail: * Required

Name:

Title:

Member#:

Member     Student/Retired/Unemployed Member     Non Member

Name:

Title:

Member#:

Member     Student/Retired/Unemployed Member     Non Member

Name:

Title:

Member#:

Member     Student/Retired/Unemployed Member     Non Member

Educational seminar fee includes materials, continental breakfast, and lunch.

Session Rates:
Register Two Attendees for $90  - Special Session Rate for Members and Non-Members

Please remit your registration form by 06/06/08 to:

Frederick Jackson, Executive Director
Wayne Memorial Community Health Centers
601 Park St.
Honesdale, PA 18431-1445
Phone: (570) 253-8450
Fax: (570) 253-8425
jacksonf@wmh.org

Please Note: To avoid being charged the full registration fee, cancellations MUST be made 72 hrs prior to the meeting date by calling or e-mailing Frederick Jackson. Thank you.

Please make your check payable to HFMA NORTHEASTERN PA CHAPTER.