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REGISTRATION: Emergency Physician Educational Summit - May 6 and 7, 2013
 
 
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Please complete the following form to register for Educational Classes provided through the Conemaugh Learning Institute, Department of Continuing Education.

Please note that this is not a secure website. All information you submit is given voluntarily and will only be used for services through Conemaugh Health System. Your information will NEVER be sold. 

First Name:
Last Name:
Discipline:
Street Address:
Address 2:
City:
State:
Zip Code:
   
Work Information  
Employer:
Department:
Street Address:
Address 2:
City:
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Contact Information  
Home Phone Number:
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 Payment Method  


Payment Totals

Conemaugh Health System Employees = No Charge

PRIOR to April 15, 2013:
Physicians = $150 per day
Physician Extenders, Medical Students and Residents = $100 per day

AFTER to April 15, 2013:
Physicians = $175 per day
Physician Extenders, Medical Students and Residents = $125 per day


Print this form and include with your check or money order payable to "Conemaugh Memorial Medical Center".

Mail check or money order to:
Conemaugh Memorial Medical Center
Department of Continuing Education
1086 Franklin Street
Johnstown, PA 15905