REGISTRATION FORM

Name: ________________________________________________________ Date: __________

Address: ___________________________________________________________________

City/State/Zip:___________________________________________________________________

Cell Phone: _________________________________ Work Phone:__________________________

Telephone: __________________________________ Fax: ________________________________

E-mail address: ___________________________________________________________________

Organization (if any): ______________________________________________________________

Contact person (if any): ____________________________________________________________

Course Name: ______________________________________ Course Date: __________________

Course Name: ______________________________________ Course Date: __________________

Total amount enclosed: $ ___________________________________________________________

How were you referred to FEDEN Organization:

£ Mail notice £ Website £ Flyer £ Organization/Employer £ Friend £ Other _____________

Registration Deadline: Payment and registration form must be received five (5) days prior to course date to guarantee your seating.

Payment Method
 Cash  Check  Money Order  Credit Card (For credit card, please complete information below or call)

Name of Cardholder _______________________ Signature of Cardholder ________________
Billing Address for Credit Card ___________________________________________
Acct. Number _________________________ Type: VS MC Discover Other ________
Verification code (on back of card) ______________ Expiration Date__________

FOR REGISTRATION & MAILING: Please mail the completed registration and payment to:

10556 South US Highway 1, Port St Lucie, FL 34952

PLEASE NOTE: No fees will be refunded if this office does not receive written notice of cancellation Three (3) business days prior to the start of training. Fees paid for training missed may not be applied toward any future training without prior notification & approval. A $25 processing fee will be applied to all refund. 

FEDEN Healthcare Education Institute reserves the right to refuse to provide training and/or professional services to non-compliant participants.

All training may be subject to date change or cancellation.

(copy of this form is accepted)