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 firstname.lastname@example.org 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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