Registration Form

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First Name *
Last Name *
Home Address *
City *
State/Province *
Zip or Postal Code *
Work Phone *	(999) 999-9999
Pager/cell	(999) 999-9999
Home Phone	(999) 999-9999
Please contact me during the work day by:	e-mail	work phone
	home phone	pager/cell
E-mail *
Employer/Department *
UC Davis Employee ID #
Professional License # (required for community RNs)

* Registrations are confirmed only after deposit or fee is received. All deposits must be paid separately. UC Davis employees registering from home must log in through Citrix to view employee pricing.

* UC Davis Health personnel must use their UC Davis e-mail account per hospital policy. Subsequent communication will be sent to your UC Davis e-mail address.

Note:

Special Needs:

I need special accommodations to attend the class as specified in the Americans with Disabilities Act. Note: for your privacy, please list specific accommodations needed below and do not disclose your health or medical information.

Comments:

Payment Method *

Payment with a credit card online (recommended if submitting payment)

Payment or deposit with a credit card by phone

Phone: (916) 734-9790
Mail: UC Davis Center for Professional Practice of Nursing
4900 Broadway, Suite 1630, Sacramento, CA 95820

Register button grayed-out? Employees must log in through Citrix when registering from home.

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