PRISM Enrollment

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Enrollment Form

Required Items. Please read the cancellation policies.

2008 Protocol: Program Review Instrument for Systems Monitoring
Student Information:
1st Student Name:
1st Student Email:
2nd Student Name:
2nd Student Email:
3rd Student Name:
3rd Student Email:
Agency Information:
* Agency:
Contact Name:
* Job Title:
* Phone:
Fax:
Address:
City:
State:	Zip:
Course Information:
* Course:
* Number of Students:
Course Cost:	$299 per person
* Fees:
Discounts:	Take 3 Discount (For groups of 3 or more - Deduct $25 per person)
Note:	When booking online, Take 3 discount is for 3 or more student registering for the same workshop.
* Total Fees:

Payment Method:
* Payment Method:	PO#:
	Please bill the company: letter of authorization or purchase order will be faxed to (901) 758-4036. I have read and understand the registration and refund procedures for HSU courses.
Card No:
Expiration Date:
Security Code:	(3-digit security code on back of card)
Name on Card:
Authorizing Manager:
Comments:

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HSU provides a range of services to allow persons with disabilities to participate fully in educational programs and activities. If you desire support services, contact the student Access Center at (901) 758-4034.