Registration Form

Name:
Street Address:
City:
State:
Zip:
Home Phone #:
Work Phone #:
Fax #:
Email address:
Registering for:

If you prefer to download the registration form, fill it out and mail it in click here.

Please make check payable to:   Collins Healthcare Education, Inc. and mail to: P.O. Box 780251, Orlando, FL 32878-0251


For the convenience of using PayPal a service charge is added to the original cost of the education.

Activity Education
 
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