1) Name and Address

Name:        *
Address:    *
Address2:
City:           *
State:                 ZIP:  
Phone:            FAX:  

Email:        

1) Your occupation: (please enter all that apply)

Interpreter      Manager   Physician     Nurse
Administrator   Other Health Professional Trainer or Educator
Health Interpreter Advocate  Health Technologist
Other                Please Specify

2) Are you a CHIA member? No, I am not yet a CHIA Member Yes, I am a CHIA Member  

3) Registration Cost: Select from pull down menu CHIA Member: No Charge! Not a CHIA member *

4) Enter any comments you may have in the space provided below:

Please call Tatiana Viscaino-Stewart to confirm your registration for this workshop (phone:  209-724-0102)     
by fax:  209-724-0153

We look forward to seeing you at the Workshop in Merced!