City ________________________________ State _____ Zip _________
Work Phone (________)________________________________
CSH Coordinator E-mail (required for confirmation*)
__________________________________________________________
*Your confirmation will be sent to you via e-mail.
Four Ways to Register
By Phone: (800) 477-8277
By Fax: 423-899-4547
By Mail: Tennessee Coordinated School Health Institute
c/o National Center for Youth Issues
P.O. Box 22185
Chattanooga, TN 37422-2185
Make your check or purchase order payable to National Center for Youth Issues. Then mail the check or purchase order and registration to the address above.
Institute Fee: $50 per participant
CSH Coordinator - $50
$________
CSH Coordinator Assistant - $50
$________
Additional Staff Member - $50
$________
Total
$________
Payment Method
Purchase Order# _______________________________________________
(please attach a copy of the purchase order)
Check (enclosed)
Credit Card :
Personal
Corporate
Credit Card Type:
MC
Visa
Discovery
Amex
Card No.________________________ Exp. Date _______
Name on Card (Please Print)_______________________________________________
