Rm 148, 413 Industrial Park Ave., Asheboro, NC Registration limited to Sandhills Center MCO staff & providers (limit of two persons per agency). Space is limited. Please register early. To Register: CASCE #56872 Fill out the shaded areas, save, & email it to (preferred), or fax this form to: 910-323-0674 Dr. Mr. Mrs. Ms. Employer: Name: Work Address: Last 4 digits of SSN: Degree: City, State, Zip: Home Address: Work County:: Work phone: City, State, Zip: Job Title: Your Specialty Areas: Home County: Hm. phone: (i.e., substance abuse, developmental disability, etc.) CHECK:I am a Sandhills Center Staff member: I am a Sandhills Center contracted Provider: Preferred Email address: Please note: We will only contact you by email. Please print or type. ..Important Information If you need any of the auxiliary aids or services identified ……… … ……… in the Americans With Disabilities Act of 1990 in order to Substitutes/Refunds/Transfers attend any of these programs, please call (910) 678-7305. If you register for a program and cannot attend, you may Our Promise To You send a substitute or cancel 48 hours in advance. Southern Regional AHEC strives to offer the highest Questions And Suggestions quality educational programming. If, for any reason, any Please contact Kate at (910) 678-7305, or email her of these programs do not meet your needs, please let us at kate.smith@sr-ahec.org. know. We value your feedback and will resolve the issue Americans With Disabilities Act to your satisfaction.
Rm 148, 413 Industrial Park Ave., Asheboro, NC Registration limited to Sandhills Center MCO staff & providers (limit of two persons per agency). Space is limited. Please register early. To Register: CASCE #56872 Fill out the shaded areas, save, & email it to (preferred), or fax this form to: 910-323-0674 Dr. Mr. Mrs. Ms. Employer: Name: Work Address: Last 4 digits of SSN: Degree: City, State, Zip: Home Address: Work County:: Work phone: City, State, Zip: Job Title: Home County: Hm. phone: Your Specialty Areas: (i.e., substance abuse, developmental disability, etc.) CHECK:I am a Sandhills Center Staff member: I am a Sandhills Center contracted Provider: Preferred Email address: Please note: We will only contact you by email. Please print or type. ……… ..Important Information … ……… Substitutes/Refunds/Transfers If you register for a program and cannot attend, you may send a substitute or cancel 48 hours in advance. Questions And Suggestions Please contact Kate at (910) 678-7305, or email her at kate.smith@sr-ahec.org. Americans With Disabilities Act If you need any of the auxiliary aids or services identified in the Americans With Disabilities Act of 1990 in order to attend any of these programs, please call (910) 678-7305. Our Promise To You Southern Regional AHEC strives to offer the highest quality educational programming. If, for any reason, any of these programs do not meet your needs, please let us know. We value your feedback and will resolve the issue to your satisfaction.
Clinical-Service-Documentation-8-16-18.docx