Registration Forms for Anesthesiologists Register Online Date of Workshop You Wish to Attend:* October 24-25, 2009 December 5-6, 2009 February 20-21, 2010 April 17-18, 2010 May 22-23, 2010 October 9-10, 2010 December 4-5, 2010 Name:* Profession: Degree: Address:* City:* State:* ZIP:* Country:* Business Phone:* Home Phone: E-Mail Address:* I work as: Private Anesthesiologist Faculty in an academic department PG1 PG2 PG3 PG4 Fellow CRNA SRNA Medical Student Other (please specify) Institution: Please estimate how many nerve blocks do you perform per month: None Less than 10 Between 10 and 20 More than 50 What is your objective assessment of your own skill level in Regional Anesthesia? Novice Intermediate Advanced I was referred to RASCI by: I have special dietary preferences: Yes No Please Specify: Payment method: Cost: $1,750 Two Day Regular Workshop To pay by check, please send check to: RASCI, Department of Anesthesia University of Iowa 200 Hawkins Drive 6-JCP Iowa City, IA 52242-1079 Please make checks payable to: Department of Anesthesia, University of Iowa * Indicates a required field. Register Via Mail or FAX Complete the PDF form below and mail or fax it to: Regional Anesthesia Study Center of Iowa University of Iowa Health Care Dept. of Anesthesia 200 Hawkins Dr., 6 JCP Iowa City, IA 52242-1079 Phone: 319-384-9273 FAX: 319-356-2940 Download this attachment and follow the instructions to enroll in this workshop. Click Here   In order to view these files, you will need to have Adobe Acrobat Reader installed on your machine. This is a FREE application available here.