Registration Form     
 

Please type in the name and date of the program you would like to attend:
Program Name:   Program Date:
                                         
*** For CCMH Employees, please enter your name, dept & ext only.  You do not need to enter any additional information.

Name: Dept:  Ext:

Address:

City:      State:      Zip:    

Phone (including area code)   E-mail:                  

Organization:

Make checks payable to: Camden-Clark Memorial Hospital

Mail to:  Educational Services, PO Box 718, Parkersburg, WV 26102

For more information call:  ( 304) 424-2749 or 424-2296

Fax: (304) 424-2688