Event Registration

First Name: Last Name: Occupation: Organization: Address: City: State: Zip: Phone: Email: Fax:

Are You A Child Passenger Safety Technician:

Yes      No

Select the course you would like to attend:

Riley Hospital for Children, Indianapolis, IN | June 19-20, 2008 Riley Hospital for Children, Indianapolis, IN | September 4-5, 2008

Payment Method:

Pay online now (via link to IU Pay)      Bill later

If you have questions about completing the online form or about one of the training courses, please call 1-800-755-0912.