Student Name:__________________________________  Email:__________________________________   Phone:________________________

Address:________________________________________________   City:_____________________________________   Zip:______________

Course Date: ________ /_________ /_________         Workshop #: ____________________________________              Amount paid: $125


Course cost: $125* (Approx $240 total, including student materials, tax, S&H)

* Student Materials required for AWHONN courses, see below                

Pay $125 for course fees by:      [  ]  Check or money order​​          [   ] PayPal -​          

​​[  ] Venmo - KlevGirl           
[  ] Credit/debit card:      Visa   /   MasterCard   /  AmEx  (circle)
                                                  [  ] ​Apple Pay (951) 236-8117

   Credit/Debit Info:  Name on Card _____________________________________________  

​​                                   Billing Zip Code:  _________________   Exp Date__________________

                                   Card # ​​__________________________________________________

3 Digit Security code on the Back of Card: _________



* AWHONN Course Materials: Student material packs are required for all AWHONN FHM classes. The cost for the Advanced FHM student materials         is approx. $115 (incl tax, S&H).
​Purchase student materials before class from Kendall Hunt. Allow 1-2 weeks for delivery.  The materials must be 5th edition!
​You will need the course date and Workshop #. The ISBN # for materials is: 978-1-5249-3308-1. Kendall Hunt 1-800-228-0810 

​​The exam is taken at home after the course. You will need the code from new, unused AWHONN Materials to complete the exam and course evaluation
Mail completed form and payment to: Karen Kleveno MSN-Ed
​ The Rockin' K Ranch:  16105 Reiner Cir Riverside, CA 92504
Email:​    Phone: 951-236-8117

[    ]  Download & complete class application
[    ]  Mail application with payment of $125 (cash, check, PayPal, Venmo or credit card) to Karen Kleveno (16105 Reiner cir Riverside, Ca 92504).             ​       If you are paying with credit/debit, Venmo or PayPal, you may take a photo of the application and text or email it to me
[    ]  Order student materials from Kendall Hunt at least 1 week before class  (1-800-228-0810) ISBN # 978-1-5249-3308-1
[    ]  Arrive between 8:45 to 9:00. We start promptly at 9:00 (please do not arrive before 8:45)
[    ]  Come hungry! Breakfast & lunch are included with the AFHM courses
DO NOT SEND ME $240   
Do not send your application requiring a signature. I am usually not available to sign for packages or letters. ​Thanks!
​AWHONN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accredidation

AWHONN also holds a Ca BRN number: Ca CNE Provider #CEP580

Accredited Status does not imply endorsement by AWHONN or ANCC​​​​​​ of any commercial products displayed or discussed in conjunction with an activity
By completing this application and registering for this course, you accept all responsibility for any injuries which may occur while on the premises, attending class. ​The Rockin' K Ranch, its owners, and the class instructors accept no responsibility for lost items or injuries resulting from course participation.
Square is used to bill credit/debit cards. How do you prefer to receive your credit/debit receipt?

​[ ]Text:_______________________  [ ] Email______________________________________