HDR Workshop Registration Form

Workshop Registration Form
Please complete one form for each workshop you are registering for. * Indicates required field.

Full Name: *

Street Address: *

City or Town: *

State:

Zip / Postal Code: *

Business Phone:

Home Phone: *

Title/Position:

Company/Organization:

E-mail: *

Workshop Title No. & Fee:

Title: *

Number: * Fee: *

Method of Payment: ( If paying by check, see below)

Check is enclosed for : $

Please charge to my Credit Card

Type of card: Business Personal

Name as it appears on card:

Credit Card:

Card Number:

Exp. Date:

Card Billing Address: Check here if same as address listed above.

Address:

City:

State:

Zip Code:

If you are paying by check please print out this form and mail with payment to:

HDR Educational Services
1994 East Rum River Drive South
Cambridge, MN 55008-2663

Ph: 1-800-243-5383

"Working Together…Making a Difference."
It's Not a Slogan, It's Our Philosophy.

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HDR Educational Services is a division of Health Dimensions Rehabilitation, Inc. The goal of HDR Educational Services is to provide and encourage training and education in order to promote personal and professional growth and development. Click here to check out our current workshops!

Health Dimensions Rehab, Inc.
1994 East Rum River Drive South
Cambridge, MN 55008-2663

Phone :	800-243-5383 763-689-5385
Fax :	763-689-5558

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