| Name | First | Last | Course Title | Payment Type | Email | REHS Number (Note if registering with no REHS number or from out-of-state, please use 5000.) | Your Phone Number | Can Your Phone Number be used for texting? | NC County Health Depts & Districts (If retired, unaffliated or other employment, denote as NA and go to the next box.) | Other | Supervisor’s Name | Supervisor’s Phone Number | Can Your Supervisor’s Phone Number be used for texting? |
| Name | First | Last | Course Title | Payment Type | Email | REHS Number (Note if registering with no REHS number or from out-of-state, please use 5000.) | Your Phone Number | Can Your Phone Number be used for texting? | NC County Health Depts & Districts (If retired, unaffliated or other employment, denote as NA and go to the next box.) | Other | Supervisor’s Name | Supervisor’s Phone Number | Can Your Supervisor’s Phone Number be used for texting? |