RWJUH EMS & Trauma Education -- Robert Carell Trauma Symposium Registration Form

EMS & Trauma Education

Robert Carell Trauma Symposium Registration Form ALL REGISTRATIONS MUST BE PRE-PAID. No seats will be reserved or certificates/credit awarded without payment. No refunds or credits will be issued for incomplete coursework, failures or absences. Click here for our refund and cancellation policy. Student substitutions for a particular course are allowed up to the end of the business day preceding the course without fee or penalty. A fee will be assessed for returned checks and certificates/credit will be withheld until payment has been completed. Available seats are filled on a first come-first served basis. Only preregistered students will be notified if the course is cancelled or rescheduled. EMS & Trauma Education reserves the right to reschedule or cancel seminars for lack of interest as measured by the number of preregistered students. RWJUH (New Brunswick) employees should contact EMS & Trauma Education at 732-937-8686 (hospital x8686) for special registration information. Telephone or e-mailed registrations will not be accepted. Registrations with credit card payment can be faxed with a cover page to "Course Registration" at 732-418-8199. Students should complete the registration form below, which may be duplicated, and send it with payment to: EMS & Trauma Education, Robert Wood Johnson University Hospital, One Robert Wood Johnson Place, P.O. Box 2601, New Brunswick, NJ 08903-2601

*** Incomplete registration forms or those without payment will not be processed and may be returned. ***

Name Professional level:

Address Date

DOB

ID#/SSN

E-mail Day phone

Affiliation Eve phone

Course Title	Course Date(s)	Tuition/Fees
Robert Carell Trauma Symposium		$
Check # is enclosed. Make check or money order payable to "The Trauma Education Fund."		Total $

For Credit Card Payment Only

Card Type (check one): [ ] American Express [ ] MasterCard [ ] VISA [ ] Discover Card

Cardholder's Name

Card Number

Expiration Date

Please read and sign below this statement: I agree to pay the total amount noted above per the card issuer agreement.

Cardholder's Signature:

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Name	Professional level:
Address	Date
	DOB
	ID#/SSN
E-mail	Day phone
Affiliation	Eve phone

Card Type (check one):	[ ] American Express [ ] MasterCard [ ] VISA [ ] Discover Card
Cardholder's Name
Card Number
Expiration Date