REGISTRATION FORM (please print) NAME: _________________________________________________

1. Preceptor WorkshopJanuary 22th: 9AM – 1PMSt. Luke Episcopal Hospital: Denton Cooley Auditorium KEYNOTE SPEAKER: Michele Deck MEd, BSN, LCCE, FACCE “Leading the Flight to Deliver High Quality Patient Care” Check/Money Order: payable to St. Luke's Episcopal Hospital Credit Card: MasterCard/Visa Discovery American Express Credit Card Number: _____________________________________________ Expiration Date (M/Y): ____________________________________________ Name on Card (print clearly): _________________________________________ Authorized Signature: _______________________________________________ Registration Questions: LaVerne Harris @ 832-355-4456 If paying by credit card, you can email registration form to: Lharris@sleh.comorfax to: 832-355-3019 Or mail registration form and payment to: St. Luke’s Episcopal Hospital ATTN: Preceptor Workshop Registration Nursing & Patient Education, 4-278, Box 96 6720 Bertner Ave. Houston, TX 77030 REGISTRATION FORM(please print) NAME: _________________________________________________ Mailing Address: ________________________________________ City: _____________________ State: ___________ Zip__________ Home Phone: ____________________________________________ Employer: _______________________________________________ Work Ph No: _____________________________________________  no fee - SLEH-TMC Employees  $45 SLEH (non-TMC) Employees  $45 Non-St. Luke’s Employees Registration Closes on January 19, 2011 No Refunds after January 14, 2011 Limited Seating of 200 attendees Garage Parking: $12.00/day; Valet Parking $13.00/day Receive up to 3 contact hours. To receive contact hours, you are required to record attendance on the Certificate of Successful Completion form and complete the evaluation for each session attended. St. Luke's Episcopal Hospital is an approved provider of continuing nursing education by the Texas Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.