To REGISTER
for any program, please complete all of the information.
PLEASE
PRINT and MAIL or FAX
Name
Address
City
State
Zip
Phone
E-mail
Program title
Location
Date
Program cost
Materials
Fee:
Contact
Hr Fee: (optional)
Total
Enclosed:
Detach
and MAIL REGISTRATION FORM with CHECK OR MONEY ORDER TO:
The BirchTree Center for Healthcare Transformation, Inc.
221 Pine Street
Suite 1G4
Florence, MA 01062
Phone: 413-586-5551
Fax: 413-586-8181 info@birchtreecenter.com www.birchtreecenter.com
