Registration Form

ICU BOOT CAMP, 2008

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Applicant Information

Name:__________________________________________________________________________

Address:_______________________________________________________________________

Telephone Number:______________________________________________________________

Email Address:_________________________________________________________________

Institution:___________________________________________________________________

Position/Job Title:____________________________________________________________

Starting Date in This Position:________________________________________________

Academic Background:___________________________________________________________

(Brief) Summary of Prior Work Experience:




What is your most urgent work-related issue? What is the one thing you MUST know by the time you return from Boot Camp?




Payment by:
Institutional check _____ Institutional credit card _____
Personal check/credit card _____

I am submitting my $1000 deposit: _______
I am submitting payment for additional tuition amount of _______

Checks should be made out to:

DAIS
(Disability Access Information and Support)
and mailed to:
2938 Northwest Blvd.
Columbus, OH 43221-0192

CREDIT CARD PAYMENTS

You can now pay your tuition by credit card. Use Mastercard, Visa (Print out, fill out, then FAX or mail the registration information above AND the Credit Card form below)

Name of Registrant ____________________________________________

Institution _____________________________________________________

E-Mail: _______________________________________________________

Street Address _________________________________________________

City, State/Province ________________________________________

Zip+4/Postal Code________

Telephone __________________

Text Telephone? Yes ____ No ____

Total Amount Owed: ____________

Credit Card Type: ____ MC ____ Visa

Card Account Number:_________________________________________

Exp. Date (required)_____________________________________

Card Holder's Signature: (required)_________________________________________________________

Card Holder's Name as it appears on card:
__________________________________________________

FAX (270) 477-9450 or
MAIL to:
DAIS
2938 Northwest Blvd.
Columbus, OH 43221
(270) 477-9450 (FAX)
(614) 481-9450 (V/T)
DAIS is a sole proprietorship. The Tax ID # associated with any registration/payment is 348-38-2091.