EMERGENCY NURSING PEDIATRIC COURSE by I2CJJjl2

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									              EMERGENCY NURSING PEDIATRIC COURSE
                                              Reverification
                                              August 11, 2011
Name:                                                          Home Phone: (               )       ___________
Home Address:                                                                                      ___________
City:                                                                   State:            Zip:     ___________
eMail address: _______________________________________________________________
Place of Employment:                                                                               ___________
If payment is being made by your employer, you must list your manager or other contact information for
the person handling your request. If you have not received your course materials approximately 3-4
weeks prior to the course, please contact the course director to verify whether you are registered for the
class.
Manager’s name: _____________________________________________________________
Manager’s phone: _____________________email:___________________________________
Work Address:                                                                                               _____
Business Phone: (              )                      ________________
Position:                                                        Unit: _____________________________
RN License #:                                          ENA #:           ____________________________
Is this a Critical Access Hospital?                Yes         No       Don’t know
Deadline: Registration and payment must be received by one month prior to course.
Substitutions must be approved by course director.

You must be a current ENPC provider on the date of the course.
Please send a copy of your ENPC card with your application.
Course Fee:                $150.00 (ENA Member)
                           $175.00 (non-ENA Member)

Make Check payable to:                Indy Roadrunners ENA

Mail to:
Sherri Marley RN                                               630-2645 office
258 Adrienne Dr                                                310-5461 pager
Greenwood, In 46142                                            sherri.marley@wishard.edu

Registration will be limited. Course fee includes course materials, and break refreshments. If you have any special
needs, please contact the course director at least 30 days prior to the course
Course cancellation policy Course registrants should contact the course coordinator by e-mail or phone as early
as possible when they find they cannot attend a course, preferably two weeks in advance. Your registration may be
able to be transferred to another course in the Indianapolis area one time only.
If you are unable to attend a course and do not notify the course coordinator prior to the start of the course, no
refund will be given and your registration will not be transferred to another course.

The Emergency Nurses Association is accredited as a provider of continuing nursing education
by the American Nurses Credentialing Center's Commission on Accreditation.

								
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