Registration Form

Download Registration Form

Forms must be received by February 15, 2009

First Name_________________________________________

Last Name_________________________________________

Home Address ________________________________

City, State Zip ________________________________

Phone_______________________________________

Email Address_____________________________________

Employer/School______________________________

Work Address ________________________________

___________________________________________

City, State Zip ________________________________

Occupation: ____ ATC _____ PT _____ PTA ____OT

____ OTA_____ MD_____ Student ____Other Prof.

Fees*:	by Feb 15	On site
_____ Professional	$80.00	$100.00
Non-NATA/ATSNJ Member	$120	$140
_____ Full Time Student	$40.00	$50.00

*Professionals who are part-time students are excluded from the student fee.

*Payment or PO must be received by the Conference date to receive your CEU form.

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Workshop Selection: (If no selections are
made then you may choose from what is available the day of the conference)

If signing up for workshop A, bring workout clothing to change into the day of the conference.

Please rank sessions, by letter, in order of preference.
1st choice 2nd or 3rd

Workshop Selection _____ _____ _____

Lunch Selection; _______Chicken ________Vegetarian

Please mail this form and check/PO to:
ATSNJ Conference Registration
c/o Mary Jane Rogers
69 Susquehanna Trail
Branchburgh, NJ 08876