Registration


	Registration for HITRUST Academy
	Please complete the information below to register for training. You will be provided with a user name and password immediately upon submission of this form so that you can access course materials. Note: Items preceeded by '*' are required.
*	First Name:
*	Last Name:
*	Organization:
	Title:
*	Address 1:
	Address 2:
	Address 3:
*	City:
*	State/Province:
*	Zip/Postal Code:
*	Country:
*	Phone:
	Fax:
*	Email:
*	Email (Confirm):


	Additional Information and Payment
	If you are attending the onsite course and have any special dietary requirements, please list them below.
	If you are attending the onsite course and have any special access requirements, please list them below.
	Emergency Contact Name:
	Emergency Contact Phone:

	I am interested in the following courses:
	HITRUST Training for Practitioners (2 day online, 3 day onsite - $3,000)
	HITRUST Certified CSF Practitioner Annual Update Course (online - $1,000)

	I would like to purchase by:
	Check Credit Card Purchase Order Coupon Code

Registration for HITRUST Academy