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Division Home
Preparing the Front Line: Ready to Respond, June 18 and 19
PLUS . . . Basic Disaster Life Support (BDLS), June 17
Registration Form
First Name*
Initial
Last Name*
Title
Company or Institution
Address (first line)*
Address (second line)
City*
State*
TX
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
UT
VA
VI
VT
WA
WI
WV
WY
Zip Code*
Email*
Phone
Cell Phone
Class
June 17
June 18
June 19
Basic Disaster Life Support (BDLS) (7:30 registration) (CME, CNE)
(8 hours)
7:30- 5:00
Biosecurity and the Law (8 hours)
8-5
Personal Protective Equipment (PPE) for Health Departments (8 hours)
8-5
Symposium for Preparedness (4 hours)
8-12
Pandemic Planning for School Districts (4 hours) (CNE)
8-12
1-5
Mental Health in Crisis Situations (4 hours)
8-12
1-5
Rapid Assessment (4 hours)
1-5
8-12
Risk Communication (4 hours)
1-5
8-12
I wish to apply for the following specialized CEU's (check all that apply):
CME
CNE
Cost
BDLS only (17th)
$25
Both days + BDLS (17th)
$60
Both days
$35
One day + BDLS (17th)
$45
18th
19th
One day only
$20
18th
19th
Payment (check one):
Check made payable to SWCOEH and mailed to:
Southwest Center for Occupational & Environmental Health
P. O. Box 20186, RAS W1038
Houston, TX 77225-0186
Mastercard
Visa
Scholarship (for higher education students only; proof of current registration must be provided at sign-in)
Cardholder:
Card number:
Expiration Date:
Billing Zip Code:
If you do not wish to submit your credit card information online, please call Vickie Mason at (713) 500-9451 or toll-free at (866) 394-8700 with card information.
Credit card billing address (if different from address of registrant):
*required