REGISTRATION FORM

Early Bird Registration        Prior to one week of the course               $305.00 Late Registration                                            $305.00 Group rate (4 or more)         per person                                                       $305.00 Student Registration-        call for special pricing            Name             Address                                 Employer:    Home Phone:   Work Phone:    Discipline: PT OT Speech OTA PTA Method of Payment: Check Visa Master Card Discover Credit Card #:    Exp. Date:            I hereby authorize Innovative Rehab Solutions to charge the above specified amount to my credit card. I agree to comply with the card user's agreement. Authorized Signature: ______________________________ Print Name (as printed on the credit card): _________________________________ To register for this course, please fill the above form, print and send it through fax or mail. Thank you. Mailing Your Registration to: Innovative Rehab Solutions, P.O. Box 2189, Valdosta, GA 31604 Fax Your Registration to 229 242 6671.