Where Learning, Teaching and Healing come together! Allied Health, CME, Dentistry, Mental Health, NCEBP, Nursing, Online Learning, Pharmacy Medical Library, Health Careers, Housing, Pharmacy and Medical Students information Appointments, Medical Records, Clinics, Insurance Providers Applications, Salaries, Resources for employees, Staff directory
Please fill out the form below if you want your name added to our mailing list for brochures. All information submitted in the form is confidential and never shared with outside parties. This page is encrypted for security.  If you have any questions, please call our registrar @ (910) 678-7226 or email CE_Reg@sr-ahec.org
Action needed:  
*First Name:      MI: *Last Name:     
Degree/Credentials: *SSN:       
Last 6 digits only, please
Organization Name: Position  
Organization Address:   
Organization City:   Organization State: Organization Zip     
Organization County: Organization  Phone: Home Phone:
*Home Address:       *Home City:      *Home State:      Home Zip
Home County: Fax:      Business Email:
Home Email Would you like to have discipline specific program information sent to you via e-mail?

Allied Health: 

Dentistry:

Medicine:  

Mental Health:

Nursing  

 Pharmacy:

Public Health:  

  

Other

How would you like to receive your brochure... E-Mail? US Mail? Fax?

Discipline - Please check all that apply
In order to help us better serve your needs, please complete the following TWO sections of this form.  Section ONE indicates areas of interest.  Section TWO indicates specific job position and is divided by discipline.  If you do NOT see your job classification, please see OTHER.

SECTION ONE:  AREAS OF INTEREST (Check all that apply):
Please choose at least one area of interest.  You may choose more than one by pressing the control key and clicking your choice at the same time.

 List additional areas of interest here:  

SECTION TWO:  SPECIFIC JOB POSITION (Check all that apply): 

     
     

ALLIED HEALTH:

   
Please choose at least one job position.  You may choose more than one by pressing the control key and clicking your choice at the same time.

 Other

     

CME: 

   

 Physician

 Nurse Practitioner

 Physician Assistant

     

DENTAL:

   

 Dentist

 Dental Hygienist

 Dental Assistant

 Dental Lab Technologist Other

HEALTH CAREERS:

   

 Informatics Professional

 Librarian

 Other

     

MENTAL HEALTH:

   

 Chaplain/Spiritual Caregiver

 Counselor

 Licensed Professional Counselor

 Mental Health Technician/Aide

 Psychologist

 Psychotherapist

 Social Worker

 Other
     

NURSING:

   

 Childbirth Educator

 Clinical Nurse Specialist

 DOULA

 Lactation Consultant

  Nurse Anesthetist

 Nurse Midwife 

 Nurse Practitioner  Nursing Assistant/Aide/Geriatric Aide  Staff Development Coordinator/Director
     

PHARMACOTHERAPY:

   

 Pharmacist

 Pharmacy Technician

 Other

     

PUBLIC HEALTH:

   

 Biostatistician

 Epidemiologist

 Environmental Health Specialist

  Health Educator

 Other
     

OTHER:

   

 Administrator/Director

  Career Development Coordinator

 Case Manager

 Clinical Specialist

 Consultant

 Exhibitor/Vendor

 Faculty member/Instructor

 Genetics Counselor

 Manager/Supervisor

 Health Physicist   Firefighter   Office/Practice Manager

 Optician

 Optometrist

 Parent

 Principal

 Student

 Teacher

 Unaffiliated  Veterinarian   Veterinary Technician
 Other

Thank you!  Please allow up to 3 – 4 months for SR-AHEC mailings to begin arriving to your address.  If you gave us your email address, you may begin receiving e-mail communication about our upcoming programs sooner.  You can view information online about our upcoming educational programs at www.SouthernRegionalAHEC.org/continuing_ed/e_brochures.htm.