Registration

* Required Registration Information

CLP Module Name

* Select modules you wish to register for:

Acute Low Back Pain $45.00
Common Dermatological Conditions $45.00

General Student Information

* First Name:
MI:
* Last Name:
* Mailing Address:
* City:
* State:
* Zip:
* Home Phone: * Business Phone:
* E-mail Address:
License: RN LPN LMHT Number:

Personal Information

Gender:
Birth date:

Student Education

Basic nursing education:
Year of graduation from basic nursing program:

If you are a advanced practice nurse:

Type of advanced practice:
Year of graduation from advanced practice program:
APN educational preparation:
Specify which program you attended:
In what state are you licensed as an advanced health professional:
Are you nationally certified:

Professional Discipline

Select your primary occupation:
Other (please specify):
Practice setting:

Professional Organizations

ANA	Other (specify)

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(print and detach here for mail-in registration)

Course Payment Information

Please submit electronic form by clicking the "Submit Electronic Registration" button below and send payment to:

Wichita State University
Office of University Conferences
1845 Fairmount, Campus Box 136
Wichita, KS 67260-0136
FAX: 316.978.3064

For questions about registration or payment, please contact Stephanie Sauls at 316.978.6493.

* Payment for (Registrant's Name):

Payment Options

Personal/business check. (Please make payable to: Office of University Conferences)

Mail/FAX credit card information using this form. (Please use address listed above.)

Electronically submit credit card: Mastercard Visa

Card Number:

Expiration date:

Name on card:

Signature: ____________________________
(Not necessary for electronic card submission)

Not a secure server. If you do not wish to submit credit card information electronically but prefer to mail-in the information, please follow these steps:

1) print this form prior to electronically submitting the registration;
2) complete credit card information portion by hand and detach Course Payment Information Form at the 'perforated' line;
3) mail the Course Payment Information Form and payment to address listed above.

Note: You still must submit the form (using button below) to receive a valid User ID and Password, regardless of the payment option you choose.