Center for Profession Development

Patient Safety Conference – March 2008

Name _______________________________________________________Credentials_______________________

Home Address ________________________________________________________________________________

Telephone Home (__________)______________________Work (__________)_____________________________

Employer _____________________________________________________________________________________

Title _________________________________________________________________________________________

Confirmations will be sent by email: Please print clearly

E-Mail _____________________________________________________________________________________

Programs:

Pre-Conference – 9:00-12:00 Friday March 28th, 2008…………………………….@ $ 89.00 __________________

5^th Annual Patient Safety Conference………………………………………….@ $ 229.00 ___________________

Total ___________________

Discount: University of Pennsylvania Nursing Faculty, Alumni & Students.

Employees of the University of Pennsylvania Health System, The Children’s

Hospital of Philadelphia, and the Veterans Hospital of Philadelphia. ( 15% ) Discount Total_________

Payment: Grand Total_________

IF PAYING BY Visa/Master Card CHARGE: Expiration Date / /

Make CHECKS payable to University of Pennsylvania: Check # Amount $

Mail Registration and Payment to: Or Fax Registration

Janet Tomcavage To 215-573-9103

University of Pennsylvania School of Nursing

420 Guardian Drive

Philadelphia, PA 19104-6096