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LNA Review Course Registration Form
Instructor – Kathy Hopkins, RN, M.Ed., CHPN
HPNA-Approved Instructor
Saturday, April 17, 2010
8am-4pm
Registration begins at 7:30am
Community Health & Hospice, 780 N. Main St., Laconia, NH 03246
Registration Fee: $50.00 for members of NHHPCO or
$75.00 for Non-members.
Lunch Provided
NHHPCO Individual Membership $50.00 (check here if
included)___________
Total
enclosed
$_______________
Individual
Membership: $_______________
TOTAL amount enclosed:
$______________
Form of Payment: 1Check enclosed
1Credit card
Make checks payable to NHHPCO
Contact Information:
Name:
__________________________________________________________________________________________
Address:
_____________________________________________City:
______________________________ State: ___ Zip: _______
Affiliation (if
applicable):
______________________________________________________________________________________
Phone:
__________________________ Email:
________________________________________________
Credit Card
Information:
1Type:
1MasterCard
1Visa
Card Number:
__________/__________/__________/__________ Exp.
______/_______
Total Charge Amount:
$______________________
Print name of
cardholder:
_________________________________________________________________
Authorized
Signature: __________________________________________________________________Date:______________
Postal mail
registration is available until April 9th, 2010. Make checks
payable to NHHPCO. Mail with completed registration form to: NHHPCO,
125 Airport Road, Concord, NH 03301. An E-Mail confirmation notice
will be sent. Call 603-225-0900 or email info@nhhpco.org for questions
or concerns.
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