CNE Registration

 * Required Fields 

CNE Registration Form

(Complete form and print)

Name: *    Name Change

Address:*    New

City:*

State:*

Zip:*

Phone:* (H)  (W)

License #: *

Social Security #:*

WMC Employee #:

WMC:    Non-WMC:    HCA Employee:    Student: 

Visa:    Mastercard:    Card No:  
        Expiration Date:     

Signature: __________________________________________

Program:
    
Date: 

Program:
Date: 
There are three ways to register:

  1. Mail to: Wesley Medical Center, Dept. of Education,
    550 N. Hillside, Wichita, KS 67214
  2. Fax to: (316) 962-3041
  3. Phone: (316) 962-3325
NOTE: Enrollment will not be finalized until payment is received.