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Registration Form
ENLS Course
February 19, 2015
or
February 20, 2015
UR Medical Center
Rochester, New York
Full Name: _______________________________________________ (First name for badge)____________________________
University/Organization: ___________________________________________________________________________________
Preferred Mailing Address:__________________________________________________________________________________
City: ________________________________ State/Province: ______________________ Zip/Postal Code: _________________
Country: _____________________________ Telephone: (______)__________________ Fax: (______)____________________
Email: __________________________________________________________________
REGISTRATION INCLUDES: Access to online Course Materials and Exam, ENLS Certificate (requires passing grade),
Registration in NCS ENLS Provider Database, CME Certificate, Continental Breakfast, Lunch (we cannot
accommodate special meal requests).
Course Schedule:
07:30 – 08:00 Registration and Breakfast
08:00 – 17:00 (approx.) Classes, Breaks, Lunch and online test
17:00 (approx.) Adjourn
Please circle date preference:
February 19th or February 20th
PLEASE CHECK APPROPRIATE REGISTRAION FEE:
POSTMARKED & PAID
BEFORE/ON FEBRUARY 10
Attending Physician
NP/PA/Pharmacists
RN/Residents/Fellows
 $300
 $150
 $100
TOTAL ENCLOSED:
$ __________
PAYMENT METHOD Check or Money Order must be in U.S. funds payable to: Strong Memorial Hospital/ ENLS Course. There will be a
$25.00 fee charged on checks returned by the bank due to insufficient funds. Registration confirmation/receipt and further information will be
emailed.
Please mail or fax completed registration form with payment to:
Phone: (585)275-9238
FAX:
(585) 273-1126
Email: [email protected]
.
Strong Memorial Hospital/ ENLS Course
Pam Marks
601 Elmwood Avenue, Box 619-26
Rochester, NY 14642