Continuing Medical Education Registration Form

Registration Form

Continuing Medical Education Registration Form

Strain and Counterstrain Workshop

Tucson, Arizona

Upper Extremities

September 26-27, 2009

Please note: Seating is limited and registrations will be accepted on a first come-basis. Please print this form and fax to 520-299-4609.

$185Early Tuition (through August 31, 2009)
$200 Regular Tuition (after August 31, 2009)

8 Credit Hours Category 1A/.8 CEU credit hours

Please print or attach a business card. Additional registrants may duplicate this form as necessary.
Make checks payable and mail or fax first sheet to:

Tucson Osteopathic Medical Foundation

3182 N. Swan Rd.

Tucson, AZ85712

PHONE (800) 201-8663 or (520) 299-4545
FAX (520) 299-4609

Name______

Address______

City/State/Zip______

Business Phone ( )______Fax ______E-Mail______

__ D.O. __ M.D. __ Physical Therapist __ Other______

AOA Number______

My Check in the amount of $______is enclosed.

Please charge to my ___MasterCard ___Visa___American Express

Acct. No.______

Exp. Date______

Signature______Date ______

Recommendations:
Each participant should have Dr. Myers’ Clinical Application of Counterstrain Book. Copies will be available at a discounted rate of $87.96 for purchase at the workshop.

Dates and Times:

Saturday, September 26, 2009

1:00 p.m. – 1:30 p.m. Registration

1:30 p.m. – 3:00 p.m. Workshop

3:00 p.m. – 3:30 p.m. Break

3:30 p.m. – 5:30 p.m. Workshop

Sunday, September 27, 2009

7:30 a.m. – 8:00 a.m. Breakfast/Registration

8:00 a.m. – 10:30 a.m. Workshop

10:30 a.m. – 11:00 a.m. Break

11:00 a.m. – 1:00 p.m. Workshop

1:00 p.m.Adjourn

Housing

For your convenience a block of rooms has been reserved for workshop participants at the Sheraton Tucson Hotel & Suites. A special weekend rate of $119.00 for a standard room or $129 for a suite is available until September 11, 2009. After that date, room reservations will be on a first-come, first-serve basis. Make all personal room reservations directly with Ana Piveral at (520) 784-7507. Indicate that you are with the Tucson Osteopathic Medical Foundation group.

Food

Complimentary afternoon refreshments will be served on Saturday as well as a breakfast on Sunday.

Emergency Phone Messages

During workshop hours participants may be reached by phone at (520) 299-4545 or (520) 975-0357.

Refunds

Pre-paid registration fees will be refunded uponwritten notice of cancellation before September 25, 2009 minus $50 for processing fees.