Registration for Virtual Epi-Pen & Med Admin Training First Name * Last Name * Email * Town/Organization * Phone * Attendee 1 * Attendee 1 Course & Date Selection * (Select/Deselect All) Thursday, June 13, 2024 Tuesday, June 18, 2024 Epi Pen ($45): 6:00 - 7:00 PM Med Admin ($50): 7:00 - 8:30 PM BOTH ($63): 6:00 - 8:30 PM Attendee 2 Attendee 2 Course & Date Selection (Select/Deselect All) Thursday, June 13, 2024 Tuesday, June 18, 2024 Epi Pen ($45): 6:00 - 7:00 PM Med Admin ($50): 7:00 - 8:30 PM BOTH ($63): 6:00 - 8:30 PM Attendee 3 Attendee 3 Course & Date Selection (Select/Deselect All) Thursday, June 13, 2024 Tuesday, June 18, 2024 Epi Pen ($45): 6:00 - 7:00 PM Med Admin ($50): 7:00 - 8:30 PM BOTH ($63): 6:00 - 8:30 PM Attendee 4 Attendee 4 Course & Date Selection (Select/Deselect All) Thursday, June 13, 2024 Tuesday, June 18, 2024 Epi Pen ($45): 6:00 - 7:00 PM Med Admin ($50): 7:00 - 8:30 PM BOTH ($63): 6:00 - 8:30 PM Attendee 5 Attendee 5 Course & Date Selection (Select/Deselect All) Thursday, June 13, 2024 Tuesday, June 18, 2024 Epi Pen ($45): 6:00 - 7:00 PM Med Admin ($50): 7:00 - 8:30 PM BOTH ($63): 6:00 - 8:30 PM Attendee 6 Attendee 6 Course & Date Selection (Select/Deselect All) Thursday, June 13, 2024 Tuesday, June 18, 2024 Epi Pen ($45): 6:00 - 7:00 PM Med Admin ($50): 7:00 - 8:30 PM BOTH ($63): 6:00 - 8:30 PM Attendee 7 Attendee 7 Course & Date Selection (Select/Deselect All) Thursday, June 13, 2024 Tuesday, June 18, 2024 Epi Pen ($45): 6:00 - 7:00 PM Med Admin ($50): 7:00 - 8:30 PM BOTH ($63): 6:00 - 8:30 PM Attendee 8 Attendee 8 Course & Date Selection (Select/Deselect All) Thursday, June 13, 2024 Tuesday, June 18, 2024 Epi Pen ($45): 6:00 - 7:00 PM Med Admin ($50): 7:00 - 8:30 PM BOTH ($63): 6:00 - 8:30 PM Attendee 9 Attendee 9 Course & Date Selection (Select/Deselect All) Thursday, June 13, 2024 Tuesday, June 18, 2024 Epi Pen ($45): 6:00 - 7:00 PM Med Admin ($50): 7:00 - 8:30 PM BOTH ($63): 6:00 - 8:30 PM Attendee 10 *if more than 10 attendees, submit additional forms Attendee 10 Course & Date Selection (Select/Deselect All) Thursday, June 13, 2024 Tuesday, June 18, 2024 Epi Pen ($45): 6:00 - 7:00 PM Med Admin ($50): 7:00 - 8:30 PM BOTH ($63): 6:00 - 8:30 PM Payment Method * Send Invoice Credit Card (CRPA will email an invoice that is payable online) By selecting "Yes" below, I agree that: (1.) Payment MUST be made in order to receive ZOOM meeting access information; (2.) Cancellations must be received in writing via email to [email protected] or [email protected]; (3.) No refunds for cancellations after 1/7/25. * Yes No Are you human?
