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Enrollment Form
Required Items. Please read the cancellation policies.
Course Information
Course:
Utilizing the CA to implement ERSEA
Student Information
1st Student Name:
1st Student Email:
2nd Student Name:
2nd Student Email:
3rd Student Name:
3rd Student Email:
* Agency:

* Contact Name:

* Job Title:

* Phone:

Fax:

Address:
City::
State
Zip:
*  Course Date::
Cost of Workshop:

$249 per person
* Number of Students Required:

Discounts:

 

When registering online, Early Bird Discounts are available online with Credit Card registrations only! 
* Total Fees:
Billing Information
* Method of Payment:
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:
Additional Comments
Comments:
Need more information? Call 1-888-282-7817

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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.
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