Phototherapy Workshop Registration Form
Crowne Plaza Aire MSP Mall of America
Bloomington, MN
October 22, 2016
Please print clearly
First Name:_____________________ Last Name:_________________________ Institution/Affiliation:_______________________________________
Position Title: _______________________________________________ Credentials: ______________________________________________________
Street Address:_______________________________________________________________________________ Suite/Apt: ________________________
City: _____________________________________________ State: _____________ Zip/Postal Code: ____________Country: _____________________
Phone: _________________________Fax: ___________________________________Email:____________________________________________
PRACTICE SETTING
Inpatient Unit
Outpatient Unit
Phototherapy Unit
Extended Care Facility
Dermatology Surgery Unit
Critical Care Unit
Physician’s Practice
Day Care Unit
Other _________________________________________________________________
HIGHEST LEVEL OF EDUCATION COMPLETED
High School
Diploma-Nursing
Master’s Nursing
Associate Nursing
Master’s Other
Associate Other
Bachelor’s Nursing
Bachelor’s Other
Doctorate
PRIOR PHOTOTHERAPY EDUCATION
On the Job Training
Commercial Equipment Company Education
First Time Attending a Phototherapy Course
School Curriculum
Previous Course from DNA
Other ______________________________________________________________________
YEARS IN PHOTOTHERAPY EXPERIENCE
<1
1-2
3–5
5+
TYPE OF EQUIPMENT YOU HAVE USED IN PHOTOTHERAPY
UVA-1
UVB
NB UVB
PUVA
BB
Hand-Held for Home Use
HOW WOULD YOU DESCRIBE YOUR ROLE IN PHOTOTHERAPY EQUIPMENT PURCHASES?
Decision Maker – I make the final decision
Evaluator – I evaluate options
None of the above
Other________________________________________
Influencer – I have input on options
NURSE MEMBER – MEMBERSHIP INFORMATION (RNs, NPs, LVNs Only)
License #: ____________________
State: _______________________________ Member #: ____________________
ASSOCIATE MEMBER – MEMBERSHIP INFORMATION
Medical Assistant
Physician’s Assistant
Other
Please return competed form with payment by
registration deadline October 14, 2016.
Space is limited.
Member #: ____________________
PAYMENT INFORMATION
PAYMENT: Check Visa MasterCard
American Express
Fax: 910-246-2361
CHECK NUMBER: _________________________________
(made payable to DNA, drawn on U.S. bank in U.S. dollars)
Email: [email protected]
CARD NUMBER:____________________________________
Mail: 435 N. Bennett Street, Southern Pines, NC 28387
EXPIRATION: __________ TOTAL DUE:______________
SIGNATURE: ______________________________________
REGISTRATION FEES
Member
$325
Non-Member
$400
NAME: ____________________________________________
(Please Print)