CONGRESS ON SPINAL CORD MEDICINE AND REHABILITATION

CONGRESS ON SPINAL CORD MEDICINE AND REHABILITATION
Dallas, TX

GROUP MEMBERSHIP:
Choose all groups you are a member of (max 2 please):
	ASIA
	APS
	AASCIPSW
	AASCIN
	TLC
PERSONAL INFORMATION:
First Name:
Last Name:
Designation:	M.D. Ph.D. R.N. OT PT Mr. Mrs. Ms. Other Other:
Institution:
Street Address:
City:
State:	-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip:
Country: (if not U.S.A.)
Telephone:
Fax:
E-Mail:
NAME BADGE INFORMATION:
Name on name badge:	(e.g., Jane A. Doe, M.D. or Mr. John Smith)	What's this?
City, State or Country on name badge:	(e.g., Atlanta, GA or Toronto, Canada)	What's this?
Attendant's First Name:	(if applicable)
Attendant's Last Name:	(if applicable)
Guest's First Name:	(if applicable)
Guest's Last Name:	(if applicable)
Please check if applicable: Speaker    Poster Presenter   Moderator
Check here for special needs: Accessibility    Dietary

	Early	Regular	On-Site
PRICING INFORMATION	By 6/1/09	After 6/1/09	After 8/31/09
Member of any of the 5 partner associations	$350.00	$400.00	$450.00
Non-Member	$450.00	$500.00	$550.00
Student, Fellow, Resident (with written verification from department chair)	$150.00	$200.00	$250.00
Single Day Admission (Member)	$200.00	N/A	N/A
Single Day Admission (Non-Member)	$250.00	N/A	N/A
Single Day Admission (Student, Fellow, Resident)	$100.00	N/A	N/A
Exempt From Registration Fee	$0.00	$0.00	$0.00
Add your extras:
Attendant (includes all food and beverage & Welcome Reception)	$100.00	$100.00	$100.00
Guest (Welcome Reception only)	$50.00	$50.00	$50.00
Pre-Course	$100.00	$100.00	$100.00

Discount Code:		How do I get a discount code?

Pay by:

Credit Card Check Exempt

I am registering/paying for someone else. Your Name:

Please be sure to review the above information for accuracy BEFORE clicking Submit.

Refund and Cancellation Policy:
Registration cancellations WILL NOT be accepted by phone.
Cancellations MUST be in writing.

• A $75 fee will be assessed and the balance refunded for cancellations postmarked through July 15, 2009.
• NO REQUESTS FOR REFUNDS WILL BE ACCEPTED AFTER JULY 15, 2009.
• Refunds will not be issued until after the meeting.
• Partial or full fees that have been forfeited cannot be applied to subsequent years.