Registration
RIALA Assisted Living Nurse Training June 28th & 25th
Residence:
Contact:
Address: City: St Zip:
Email: Telephone:
Registrant Name:
Title: Email:
Registrant Name:
Title: Email:
Registrant Name:
Title: Email:
Members only program. Space is limited and pre???registration is required.
Registration deadline is June 12th
Fee: $299 per person (This fee includes educational materials, continental breakfast and a light lunch)
Payment: ?–¡ Check (Payable to RIALA) ?–¡Credit Card Total enclosed or to charge $
Credit Card Information: (as listed on card) ?–¡Visa ?–¡ Master Card ?–¡ Discover
Card # Exp. Date:
Name as on card: 3 digit code:
Address: City: St: Zip:
Mail, fax, or email this form with your credit card information or a check payable to RIALA.
Address: RIALA, 2224 Pawtucket Avenue, Box 4, East Providence, RI 02914