RASCI - Registration Form

To register for a RASCI workshop fillout and submit the form below. Please note that fileds marked with an asterik (*) are mandatory.

Date of Workshop You Wish to Attend:*
Name:*  
Profession:  
Degree:
Address:*  
City:*
State:*
ZIP:*
Country:*
Cell Phone:*
Business Phone:
E-Mail Address:*
I work as:












Institution: 
Please estimate how many nerve blocks you perform per month:


What is your objective assessment of your own skill level in Regional Anesthesia?

I was referred to RASCI by:
I have special dietary preferences:

Please Specify:
 
Payment method: Cost:

$1,925 Two Day Regular Workshop

To pay by check, please send check to:
RASCI, Department of Anesthesia
ATTN: Lorri Barnes
University of Iowa
200 Hawkins Drive 6-JCP
Iowa City, IA 52242-1079

Please make checks payable to:
University of Iowa / RASCI
* Indicates a required field.
Register Via Mail or FAX
Phone: 319-384-9273 FAX: 319-356-2940