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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«
Fax Number
E-Mail Address
Employer
Person paying for course
How would you like confirmation sent?	E-Mail Fax
Course Name«
Course Date«
Fields marked with "«" are required.

This page last updated on­ Mon Apr 14, 2008 11:08 AM