Registration Form
The Porrath Foundation For Cancer Patient Advocacy Presents The Cancer Patient Advocate
Saturday, March 31, 2007 The Breast Care Center 230 S. Main St. Orange, CA 92868 CME Accreditation Persons attending this course may report up to 7 hours of category 1 credit toward the California Medical Association Certificate in Continuing Medical Education. Mail to: The Porrath Foundation for Cancer Patient Advocacy 435 N. Bedford Dr. Ste 404 Beverly Hills, CA 90210
Fax to: 310-271-3821 |
Your Information Print clearly and fill in all details, so that we can process your information properly.
_______________________ Name
_______________________ Title
_______________________ Organization
_______________________ Address
_______________________ City/State
_______________________ Zip Code
_______________________ Work Phone
_______________________ Home Phone
_______________________ E Mail Address
What is your interest in this Program?
_______________________
_______________________ _______________________ |
Payment Method To ensure your place at the Cancer Patient Advocate Training course, payment must accompany registration: __Payment of $150.00 __Check/money order enclosed
Patient Advocacy Charge to the following credit card: __Amex __MasterCard __Visa
_______________________ Card Number
_______________________ Exp. Date
_______________________ Name on Card
_______________________ Signature
Cancellations must be in writing. Refunds minus a $20 processing fee are available until 3 weeks prior to the course. No refunds after that. Contact Us The Porrath Foundation for Cancer Patient Advocacy 435 N. Bedford Dr. Ste 404 Beverly Hills, CA 90210 ms@porrathfoundation.org |