Mini Medical School

Mini-Medical School Registration Form
March 2, 2010 - April 6, 2010
E4136-10-Y

Name:
Home Address:
City:
State:		Zip Code:
Daytime Phone:
Evening Phone:
Fax Number:
Date of Birth:
Occupation:
Employer:
HMC/COM employees provide dept name/mail code
E-mail Address

I am a teacher desiring Act 48 credit

Past sessions of Mini-Medical School have filled to capacity. In order for us to accommodate as many people as possible, we ask that you register for only those sessions which you plan to attend.
March 2, 2010:
March 9, 2010:
March 16, 2010:
March 23, 2010:
March 30, 2010:
April 6, 2010:
Do you require special services (i.e., handicapped access, hearing impaired, etc.), and if so, what services do you require?
By pressing the "Submit" button below, the information will be submitted to the Continuing Education office via our secure server. Your registration will be confirmed via e-mail within one week. Your registration is not complete until you receive a confirmation via e-mail from ContinuingEd@hmc.psu.edu

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