Northwestern Perinatal Center Course
Registration Form

Instructions

If your course does not require payment, please submit the registration form online. However, if your course requires payment, you must print and mail the registration form with check or money order. Please make the check or money order out to "Northwestern Perinatal Center" and mail it to the Northwestern Perinatal Center, Prentice Women's Hospital, Room 9-2243, 250 E. Superior St., Chicago, Illinois, 60611. When your registration has been processed, you will be sent a course confirmation. Please bring it with you to the course.

First Name*

Last Name*

Title*

RN, MD, RT, etc.

Address*

City, State, Zip*

Phone Number*

(xxx-xxx-xxxx)

Fax Number

E-mail Address*

Employer

Person Paying for Course

How Would You Like Confirmation Sent?

E-mail Fax

Course Name*

Only applies to, Network Hospitals, for the March 1st STABLE Course.
Note: if you bring your own book the $45 registration fee will be waived.

Need a STABLE book?

Yes – I will mail the registration fee; $45 (covers registration fee and book).

No – I plan to bring my own book. This waives my registration fee; course is free to me.

Course Date*

(mm/dd/yy)

Fields marked with * are required.

Northwestern Perinatal Center CourseRegistration Form

Instructions

Northwestern Perinatal Center Course
Registration Form