LLUMC Staff Development Registration Form

Registration form

USE ONLY FOR CLASSES COORDINATED BY STAFF DEVELOPMENT.
Registration information

By mail: By phone: By fax:
Staff Development
Loma Linda University Medical Center
P.O. Box 2000 MVP Suite 11
Loma Linda, California 92354
 (909) 558-3500
 (909) 558-3541

Program title _____________________________________________

Program date ____________________________________________

1. Participant information
Name ______________________________ Work title _______________________________
Address ______________________________ Hospital/agency _______________________________
City/State/Zip ______________________________ Day phone _______________________________
Professional license or registration # ________________________________

LLUMC/LLUCH/LLUBMC Employees only:
Employee number _______________________ Unit/area _______________________________

2. Method of payment

___ Free tuition for employees (This does not apply to all courses.)**See registration information for your course.**
Note: Some courses may require a $20.00 refundable deposit to register. **See registration information for your course.

___Check enclosed (Make payable to LLUMC.)
Amount $______________


___Credit card
Account no. ________________________________________
Exp. date ________________ Amount $______________
Cardholder signature ____________________________________________

Loma Linda University Medical Center, Children's Hospital, & East Campus