Registration Form

Online registration is not available. Please use your computer to complete this form. Print and mail or fax the completed form to the GEPN office (see below).


Name:
Highest Degree:
Job Title:
Nursing Specialty:
In which role do you spend most of your time?
Minority
Minority Type:

If you are faculty, please list the school in which you are employed.
School:
School Address:
School City:
School State:
School Zip Code:
School Country:
The school is classified as

Preferred Mailing Address:
School Organization Home
Organization Name:
Street Address:
City:
State:
Zip Code:
Country:
E-mail:
Daytime Phone Number:
Fax number:

Please indicate any GEPN educational offerings you have previously completed (select all that apply):
Genetics Summer Institute
Web-Based Genetics Institute
Applying Genomics in Nursing Practice
One or more GEPN Independent Self-Paced Modules



Offering #1:  Web-Based Genetics Institute - January 11 - May 20, 2016, $1400
Additional costs: required textbooks. Remember to include your check, money order, credit card information or purchase order number with your registration.
Offering #2:  Applying Genomics in Nursing Practice - March 7 - April 15, 2016, $500
Remember to include your check, money order, credit card information or purchase order number with your registration.
Offering #3:  Applying Genomics in Nursing Practice - May 16 - June 24, 2016, $500
Remember to include your check, money order, credit card information or purchase order number with your registration.
Offering #4:  Web-Based Genetics Institute - July 18 - November 25, 2016, $1400
Additional costs: required textbooks. Remember to include your check, money order, credit card information or purchase order number with your registration.
Offering #5:  Applying Genomics in Nursing Practice - September 12 - October 21, 2016, $500
Remember to include your check, money order, credit card information or purchase order number with your registration.
Offering #6:  Nursing School Curriculum Modules $450 (starting 1/1/16 $500) for the CD-ROM containing 14 modules with files saved as portable document file (.pdf).
Remember to include your check, money order, credit card information or purchase order number with your order.

Group rates for the WBGI are available. 5 - 8 employees from the same organization registering for the same WBGI session can do so at a rate of $1200 per person. ≥ 9 employees from the same organization registering for the same WBGI session can do so at a rate of $1100 per person.



PAYMENT METHODS (Children's Hospital Medical Center's Tax ID#: 31-0833936)

Check or Money Order - Make payable to Children's Hospital Medical Center
Purchase Order #:  
Credit Card: MC VISA AmEx
Card Number:  
Expiration Date:  
Cardholder's Printed Name:  
Cardholder's Signature:  


Reminder: Please print the completed registration form and mail or fax it to the GEPN Office.


Mail to:
Cynthia A. Prows, MSN, APRN, FAAN
Genetics Education Program for Nurses
Division of Human Genetics, ML - 4006
3333 Burnet Avenue
Cincinnati, OH 45229-3039
Fax: 513-636-2261
Email: gepn@cchmc.org