BOH Certification Registration Form
MAHB Member Y [ ] N[ ]
Contact Person______________________________ email________________________ Phone_________________________
| Last Name | First Name | Town | Code* | CEU /CME | Location | |
| Registrant | Code* |
| Board of Health | BOH |
| Board Secretary | S |
| Health Agent | A |
| Health Director | D |
| Public Health Nurse | PHN |
| Tobacco Control | T |
| Other - Please Specify |
CEUs will be available for RNs, CHOs RSs.
IMPORTANT! Please enter the number of registrants planning to attend each session. This is necessary to plan room assignments and ensure adequate materials.
Registrants can move between the three tracks or stay with one for the day.
Number of MAHB members X $90 =_____
Number of non-members X $135 =_____
Total payment due = $________
Payment is due 7 days before the program in the form of a check payable to the Massachusetts Association of Health Boards (MAHB)
Send this registration
form and payment to:
MAHB
56 Taunton Street
Plainville, MA 02762