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Leadership Program in Health Policy and Management

June 14 - June 20, 2009

Enrollment Request Form

To ensure maximum interaction during this program, participant enrollment will be limited. The Heller School encourages interested parties to complete and submit the Enrollment Request Form at their earliest convenience. Additional information about the program can be found by visiting our website at http://Heller.Brandeis.edu/academic/elp.html.

Please complete the following information (PRINT or TYPE) and return by fax to the number noted at the bottom of the form, or mail with your check payment to the address noted below.

Name:

Title or Position:

Specialization/Degree:

Organization:

Address:


City: State: Zip Code:

Office Telephone: Fax:
Home Telephone: Email:
Preferred Mailing Address for Course Materials(if different from above

The cost of the program is $5,200/person and covers tuition, all course materials, selected group meals and transport to and from Brandeis University and the hotel.


Please bill me
Please send me information about making a wire transfer
Check enclosed (check number)

To pay by check, please print this form and mail it to the address below. We apologize for the inconvenience, but we are unable to process credit card payments

REGISTER EARLY!!!

Early Registration and Group Discounts


Individuals and group members will receive a discount of $400/person if paid in full by May 1, 2009.

Complete Enrollment Requests, as well as inquiries about the Leadership Program, can be directed to:

Leadership Program in Health Policy and Management

Linda Purrini, Program Coordinator
The Heller School for Social Policy and Management
Brandeis University
415 South Street MS 035
Waltham, MA 02454-9110 USA

Tel: 781-736-3930 || Fax: 781-736-3905
Email: purrini@brandeis.edu || Website: http://heller.brandeis.edu