American Society of Hand Therapists - California Chapter

Cadaver Lab Course Registration Form for Cadaver Lab Course

Instructions:

After you complete this form, print it out and mail along with the check or money order to:

Susan Clark, OTR,CHT

860 University Avenue Los Altos, Ca. 94024

Course Date: June 8, 2007

Location: C.C.S.R. ( Center for Clinical Sciences Research) Bldg. ( this part of Stanford complex) Pasteur Drive Palo Alto, CA

Name: As you would like it to appear on your certificate)

License #

Address: City/Sate/Zip: Home #: Work/Cell #: Emergency Contact Info:

Fax #: E-mail: (for confirmation)

Fee: $ 125.00 payment to be postmarked no later than May 30,2007

Certificate of confirmation for 3.0 contact hours will be provided.