USF Health - College of Public Health

Safety Week Registration Form (Items in Red are required fields)

First Name
Last Name
Degrees
Prof. Title
Gender	Male Female
E-mail
Home Phone
Work Phone
Fax

Company
Department
Address
Address2
City
State
Zip
Country

ADA Describe Any Disabilities
Notes/Comments

Please check which Safety Week you would like to register for.
(Note: discount coupons are not accepted for Safety Week as these courses are already discounted)

Cancelled - February 7-11, 2011	$600.00	Wesley Chapel, FL
March 22-26, 2011	$450.00	Orlando, FL
April 18-22, 2011	$450.00	Orlando, FL
May 23-27, 2011	$450.00	Coconut Grove, FL
June 13-17, 2011	$550.00	Fort Lauderdale, FL
August 29-Sept 2, 2011	$600.00	Tampa, FL
September 26-30, 2011	$600.00	Daytona Beach, FL
October 11-14, 2011	$450.00	Orlando, FL
December 12-16, 2011	$600.00	Jacksonville, FL

Payment Method
(Note: You will not be charged until registration is confirmed.)

Cancellation Policy
Cancellation notification must be in writing (FAX or email are acceptable). A cancellation fee equal to 25% will be assessed. Written cancellations received less than 5 working days prior to the event will be charged the cancellation fee plus the per-person cost. No-shows will be billed. Substitutes are welcome without penalty.

The Continuing Professional Education Office at the University of South Florida Health Sciences Center reserves the right to cancel this activity due to unforeseen circumstances. In the event of such cancellation, only the registration fee will be returned to the registrant.

Credit Card

	Mastercard
	Visa
	American Express

Name (exactly as on card)
Credit Card Number
Expiration Date (mm/yy)
CVC Code

Check

Please make checks payable to:

USF HPCC
Office of Continuing Professional Development
P.O. Box 628263
Orlando, FL 32862

On your check, please include the program code which is printed on your confirmation and the registrants name or a copy of the registration.

Bill Later For Registrations Paid By PO

PO Number


If billing address is different than above - please list below
Company
Attn:
Address
City	State	Zip
Phone EMAIL

Security Notice

Accommodations for Disabilities: Please notify the USF OTI Education Center, 2612 Cypress Ridge Blvd., Suite 101, Wesley Chapel, Florida, 33544 or call (813) 994-1195 a minimum of ten working days in advance of the event if a reasonable accommodation for a disability is needed.

Events, activities and facilities of the University of South Florida are available without regard to race, color, sex, national origin, disability, age, or Vietnam veteran status as provided by law and in accordance with the University's respect for personal dignity.

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