Forms

Trauma and Critical Care Conference

To register for the San Juan Regional Medical Center Trauma and Critical Care Conference please complete the form below.
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Last Name
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First Name
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Address
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City
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State
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Zip Code
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Telephone Number
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Additional Attendees
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Conference Fees: $100
There will be a 3.5% transaction fee for those using credit cards
I will be paying by check.
Please select one of the following if applicable
Pay by check or PO: Please mail your check  with check payable to, SJRMC Trauma Conference:
Attn: Robbie Donald
San Juan Regional Medical Center AirCare and Trauma
801 West  Maple Street
Farmington, NM 87401


Enter your PO number in the text box below.
I will be paying for this conference in advance with a credit card
Card Type
First Name
Last Name
Card Number
CVC Code
Expiration Date (month/year)
Type of CE
Security Code
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Type Security Code

MANDATORY 

Anyone who registers as a non-SJRMC Employee needs to fill out the attached scholarship application:  FY27 Special Projects Scholarship Application_FORM.pdf

Please email, mail or fax the completed application to the following:

CONTINUING EDUCATION SCHOLARSHIP

EMS REGION I & III

PO BOX 1895

CLOVIS, NM 88102-1895

PHONE: (575) 769-2639 FAX: (575) 769-3485)

EMAIL: hensleyl@sjcounty.net
SUBMIT
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