July 20, 2008 Conference Registration Fee (SPACE IS LIMITED):

Regular fee extended through July 11th - $50.00

Late fee (after July 11th) - $70.00

To register for the conference please:

1) Please print out this page
2) Complete information below
3) Fax to (407) 303-9635 or mail to address below

Registration Form:

Name _____________________________________________

Addrerss __________________________________________

City_________________ State_______Zip Code___________

Phone (Home) (________)-____________-________________

(mobile) (_______)-____________-_________________

(office) (________)-____________-_________________

E-mail ______________________________________________

Credentials (PT, ATC, PTA, other)__________________________

Payment in the amount of $_________.00 has been made by:

Check

Credit Card

If paying by credit card:
1) Please print out this page and
2) Complete information below
3) Mail or Fax to (407) 303-9635

Credit Cards accepted: Master card / Visa /American Express

Credit Card #

Expiration Date

Authorized Signature _________________________________________

Make check payable to:
Florida Hospital Rehabilitation and Sports Medicine

mail to:
Florida Hospital Rehabilitation and Sports Medicine
ATTN: Michael Dougherty ATC
5165 Adanson Street
Orlando, Florida 32804

Cancellation Policy:

Should you cancel your registration up to 72 hours to the program, you will be refunded all but $10.00 of your course fee. Written notification of cancellation is required in order to process the refund.