Registration Form

 

Environmental Services For Front Line Staff   A Program of the Ontario Healthcare Housekeepers’Association Inc.

OHHA-“1957-2013”

  Name            ____________________________Title__________________________________

  Company     __________________________________________________________________

Address        __________________________________________________________________

City/Province ____________________________Postal Code__________________________

Phone #        _____________________________Fax #________________________________

E-mail      _________________________________________________________

 

How did you find out about this program? _________________________________________
  
  Is anyone from your Facility a Member of the OHHA?       Yes         No

 

Please select Format
[ ]        Binder-Total $150.00
[ ]        Cd-Total $135.00
[ ]        Electronically-Total $125.00
Tuition enclosed:
Payable to the Ontario Healthcare Housekeepers’ Association Inc. Please do not send cash by mail.
Signature/Date ____________________________________________________

Supervisor Contact Information (if applicable)
Name:___________________________________________________________
Title:____________________________________________________________
Phone:___________________________E-Mail:__________________________

Send your completed form with payment to:
Wendy Boone-Watt, Executive Director
2053 County Rd 22
Bath, ON.
K0H 1G0
Boonewatt@kos.net

Office Use Only
Registration Received __________________________________Course Material Out__________________________________

Preceptor/Resource __________________________P/R Notified __________________Completion Date___________________

Final Mark ________________________ Certificate Out ________________________        Member      (Y)         (No)

Visit our Web Site at www.ohha.org