Burn Evaluation and Care for Medical Personnel

	Please fill in this form to register. The red dots indicate required fields.
	Title
	First name
	Last name
	Organization/Agency/School
	Position/Job Title
	Years in Current Position
	Total Years Work Experience
	Areas of Expertise/Professional Discipline
	*Other Area of Expertise
	Street Address Line 1
	Street Address Line 2
	City
	State
	ZIP Code
	Phone (xxx-xxx-xxxx)
	Fax (xxx-xxx-xxxx) (for CME delivery)
	Email			Your confirmation email and any other email with additional details about this course will be sent to this address.
	Gender
	Year of Birth (xxxx)
	Race
	Persons with disabilities or special needs should send a description of any services needed to Tammy Nix at tjnix@uab.edu or call 205-975-8971.


	Press the button to confirm your registration.