Mid-Atlantic Renal Coalition

Do we have your email?
Click here to sign up for MARC news & updates.
Need to update facility staff who receive MARC mail?
Click here to submit changes.


Search
	WWW MARC Website

Contact

Site Map

All About Access
featuring
AV Access Occlusion and Ulceration
Access Adequacy
ABCs of Access Care
and continuing education credit!

Registration Form
Please note that this registration page is to be completed only if paying by credit card. If you wish to pay by check, please download the registration form and mail it to us with your payment.

This workshop is open to all interested dialysis facility staff. Seating is limited, so please register early. The registration fee for registrations received after the June 5th deadline will be $20. Registration fees are non-refundable after the deadline. A substitute may be sent for a registrant who is unable to attend. All registered persons are responsible for payment even if he/she does not attend the meeting.

STEP 1 -	*Registrant Information*
Name:
Job Title:
Facility:		Provider #:
Address:
City:
State:		Zip Code:
Phone:		Fax:
Email:

How would you like to receive your confirmation*? Fax E-mail
*If you do not recieve a confirmation, you may not be registered!

STEP 2 - Continuing Education Credits
Please indicate if you will need education credits for:
Dietitians
Nurses
Social Workers
Technicians

Do you have Patient Care Technician certification?
Yes
No
Not Applicable

STEP 3 - Fee Schedule & Payment Method
Please indicate how you are registering (i.e. General Registration, Patient, etc.)
General Registration (after 6/5) $20
Patients, MARC Board Members FREE

Please indicate your payment method:
Check
Credit Card

If you have questions about the meeting or your registration, please contact Samantha Dorr at 804-794-3757 or by email at sdorr@nw5.esrd.net.

back

1527 Huguenot Road
Midlothian, VA 23113
804.794.3757
marc@nw5.esrd.net

Toll Free Patient Number 866.651.6272