Registration Form

Name:
RN License Number:
Address:
Please check one: Home or Business
City:
State:
Zip:
Company/Affiliation:
Daytime Phone: (ex. (xxx-xxx-xxxx)
Email Address:
Preferred means of contact Email or Postal Mail

 

  


If you have any special needs, please contact us as soon as possible at (978) 934-4772 or by email at Julie_Villareal@uml.edu.  We cannot guarantee access accommodations without two weeks notice.

Children's Health Project - Center for Family Work and Community, 600 Suffolk St. 1st Floor, Lowell, MA 01854
Phone: 978-934-4772 Fax: 978-934-3026 Email: Julie Villareal