Printable Education Program Registration Form

Registration Instructions:

1. Select the program that meets your needs.
2. Pick the date and location that are most convenient for you.
3. Submit your registration and payment directly to the sponsor listed under the program date.

Payment:

Payment must accompany the completed registration form. Registration forms received without payment will not be processed until payment is received.

If you have any questions, please call our Customer Service Center at (877) 223-6866 (8am-8pm CST, Mon-Fri). Register online for selected programs.

Please print and duplicate form for additional registrants. (Please type or print clearly!)

Your Name (First, Last):

______________________________________________________

Credentials:

_____ PhD
_____ RN
_____ MD
_____ Other ____________

Title:

______________________________________________________

Organization:

______________________________________________________

Address/City/State/Zip:

______________________________________________________

______________________________________________________

Telephone (Include Area Code):

______________________________________________________

Fax (Include Area Code):

______________________________________________________

E-Mail:

______________________________________________________

Are you accredited by the Joint Commission?

_____ Yes
_____ No

Program Title:

______________________________________________________

Program Location (City/State):

______________________________________________________

Program Date:

______________________________________________________

Program Code: ______ ______ ______ ______ (It’s in “The Details” section of each program description)

Registration Fee:

$___________________

_____ American Express (accepted in most cases)
_____ Check, payable to the appropriate sponsor
_____ Visa
_____ MasterCard

Credit Card Number:

______________________________________________________

Expiration Date:

______________________________________________________

Cardholder’s Name:

______________________________________________________

Telephone (Include Area Code):

______________________________________________________

Cardholder’s Signature:

______________________________________________________

Credit Card Statement Address/City/State/Zip:

______________________________________________________

______________________________________________________

Additional Details:



Substitutions, Transfers, and Cancellation Policy
If you register and find later that you can't attend, you can send an alternate in your place. Unfortunately, you cannot transfer your registration to another JCR education program because of variability in program sponsors. However, your registration fee, less a $100 service charge, is refundable if written notice is received 30 days prior to the program. JCR reserves the right to cancel or reschedule a program due to an insufficient number of registrants or other unforeseen circumstances. Early bird registration discounts may not be used in combination with any other registration fee discounts.