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Center for Nursing Education

Registration form

   



 
First Name *  
Last Name *
Home Address *
City *
State/Province *
Zip or Postal Code *
Work Phone (999) 999-9999
Pager/cell (optional) (999) 999-9999
Home Phone (999) 999-9999
Please contact me during the work day by:  e-mail
work phone 		 home phone
pager/cell
E-Mail *
Employer/Department *
UC Davis Employee ID #  
Professional License #  
   
UC Davis Employee Deposit *  
(not available for all classes - please see course information)
please select deposit amount    $ 25    $ 50    $ 100   Not applicable
- or -  
Registration Fee
(please fill in registration amount)		  
   
Special Needs:
     I need special accommodations to attend the class as specified in the Americans with Disabilities Act. 
 
Payment Method *
 Payment by check (payable to UC Regents and dated for the day of class):
 
    Print this completed form and mail with payment to: 
  UC Davis Center for Nursing Education
  4900 Broadway, Suite 1630, Sacramento, CA 95820
    
 Payment with a credit card by phone, fax, or mail:
 
 

Phone (916) 734-9790
Fax (916) 703-9903
Mail: UC Davis Center for Nursing Education
4900 Broadway, Suite 1630, Sacramento, CA 95820
 
 
* Fields marked with an asterisk are required

Registrations are confirmed only after deposit or fee is received.