Training Institute Registration Form

How to Register Online

Please fill out the form below and click the "Submit" button. We will hold a space for three (3) business days, pending receipt of your payment. You may pay online by using the PayPal buttons on the preceding workshop page.

Register by Mail

To register for consultation groups or workshops by mail, please print out the form below and send it with a check payable to “The Trauma Center at JRI”, for the full workshop fee. Registration will be confirmed when payment is received. Space is limited, and registration will be on a first come, first served basis.


Registration Form

Please be sure to complete this form in its entirety.


Personal Information:


Name:
Degree/Licensure:
License Number:
Email Address:
Work Phone:
Home/Other Phone:
Employer if registering as part of a "Group":
Street Address:

Which training program(s) or workshop(s) are you register for?
Please specify workshop options, if relevant.


Workshop 1:
Comments/Notes:
Workshop 2:
Comments/Notes:



If you do not receive a "thank you" email after submitting your form, please email the Training Division administrative support staff, for confirmation.

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