Online Registration

For online payment, please fill out this form:
The next page will let you choose your specific workshop(s)

*are required fields

*First Name
*Last Name
*Credentials	as you would like it to appear on your certificate of attendance
Profession	OT PT PTA CHT Other
*License #
*Facility
Department Title *Speciality Area
*Work Address
*City	State Zip
*Work Phone
Home/Cell
Fax	Please fax confirmation Please add me to your list of fax updates
*E-mail	Please e-mail confirmation Please add me to your list of e-mail updates
*Home Address
*City	State Zip
Years of Clinical Experience: <1 1-5 5-10 10-15 15-20 20+ Years of Hand Therapy Experience: <1 1-5 5-10 10-15 15-20 20+ Level of Splinting Skills: beginner advanced beginner intermediate advanced How did you learn about our workshops? Do you need special accommodations Yes No If yes, please describe:

*Name on the Credit Card you are going to use:

* I read and understand the cancellation policy

Please note that the receipt for your credit card payment is NOT your confirmation. Workshop confirmation will be sent separately. It is recommended that you wait for written confirmation prior to booking non-refundable travel or lodging. If you have not received confirmation 10 days prior to workshop, please contact Rehab Education, LLC to check on status of your registration.