Education Seminar Registration Form

Serving Connecticut's Healthcare Employers For Over 25 Years

You may use this form to register for any of our Educational Seminars. If there is a fee involved, please process payment and mail to:

Workers’ Compensation Trust
PO Box 5001
Wallingford, CT 06492

Be sure to reference the educational seminar with your payment.

* Bold fields are required

Name of Attendee

Title

Company Name

Phone Number

Email Address

Name of Seminar

If additional attendees, please add below:

Name

Title

Email Address

Name

Title

Email Address

Name

Title

Email Address

Members