Training for Transformation
Registration
(You will be contacted by a DeKalb County Board of Health representative
to provide specifics regarding payment.)
First Name

Last Name

What is your role/position
in public health?

Organization

Street/PO Box

City

State and ZIP      

E-mail Address

Phone

Fax

  Select a date
   December 10, 2003 at 8:30 a.m. until 4:30 p.m.
Select a payment option


I would like to purchase the set of Training for Transformation books for $40.00.
Select a lunch option Non-Vegetarian
Vegetarian

How do you plan to apply this workshop to your work?

Special needs for access or diet

Type initials By typing my initials in the box below, I agree to pay $375.00 for the Training for Transformation workshop (includes lunch and all workshop materials) and/or the $40.00 for the Training for Transformation books. Payment and completed registration form must be received by the first day of the workshop. I also understand that there is a $50.00 cancellation fee.


  

(You will be contacted by a DeKalb County Board of Health representative
to provide specifics regarding payment.)