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  Mini-Medical School Fall 2008: Women & Cancer
 
Registration form

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* I will attend the Mini-Medical Scool at this Location:

Your Information
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*First name
*Last name
Name Suffix (Jr., M.D., R.N., etc.)
E-mail
*Home address
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*City
*State   *Zip
*Phone () -
Preferred Communication

 Guests are invited and welcome to attend this event.
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* Total Attending Mini Medical School:

* How did you hear about Mini-Medical School?
Advertisement in Prairie Fire Newspaper
Advertisement in Her Magazine
Advertisement in Metro Monthly Magazine
Advertisement in Omaha World-Herald
Advertisement in Revive! Magazine
Advertisement in UNMC Connect Magazine
Advertisement in Women's Edition Magazine
Billboard
Blue Cross Blue Shield Newsletter
Blue Cross Blue Shield Website 		E-Mail Advertisement
Flyer
From a Friend
Poster
Received brochure in the mail
Story in local newspaper
Story in Omaha World-Herald
Susan G. Komen Race for the Cure
UNMC Web site

Other (please describe below):
Other:
Please continue to send me information about future Mini-Medical Schools and other UNMC events.

Continuing Education                    More information...
If you are a nurse and will be attending Mini-Medical School to earn continuing education credits, please provide your license number and state of licensure below:    
LPN/RN License number:
State of Licensure:
Please bring your payment of $40 (cash or check) to the first session you attend.  

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