2008 South Texas Transplant Symposium Registration

2008 South Texas Transplant Symposium

Attendee's name
Address
City		State
Zip		Email
Phone:		Fax

Please Choose a Payment Method

OPTION 1: Checks

Check for $50.00 made payable to Driscoll Children's Hospital
Enclosed is my check PAYABLE TO Driscoll Children’s Hospital in the amount of $
Fill out this form and mail it with your check to the address below.

OPTION 2: Credit card

I authorize DCH to charge my:

	Master Card
	VISA
	American Express

Fill out this form and fax it with your credit card information to (361) 694-5665

Account #:

Exp. Date: (mm/yyyy)

Name as it appears on card:

Signature:

Today's date:

This form must be printed and faxed or mailed to Maria Campbell. We do not collect credit card information online.


Driscoll Children's Hospital Maria Campbell Phone (361) 694-4117 Fax (361) 694-5665 3533 South Alameda Street Corpus Christi, Texas 78411 Email: Maria.Campbell@dchstx.org Visit our website: www.driscollchildrens.org/cme	NO REFUNDS will be issued after March 21, 2008. Location: Education Service Center- Region 2 Auditorium (Room 3-11) 209 N. Water Street Corpus Christi, Texas 78401 PRINT AND FAX THIS DOCUMENT TO (361) 694-5665