Physical Therapy Association of Washington Conference Registration Form

A Chapter of the American
Physical Therapy Association

2012 Spring Conference Registration Form
April 27-28, 2012
Lynnwood Convention Center, Lynnwood, WA

Registrant Name (to be used on name badge)

APTA Member Number
or Nonmember
(New APTA members who have not yet received a member number MUST submit a copy of their membership application form to receive the member rate. OTs and COTAs may register for the courses at the member rate if proof of WOTA membership accompanies this registration.)

Do not release my name and address to exhibitors.

Business Name

First Name

Last Name

Address

Address Line 2

City

State Zip

Country

Work Phone

Home Phone

Email

Check all that apply:
PT PTA OT COTA Life Member Retired Member Other Profession:

PT Student PTA Student School Attending:

Please choose your course(s)

Important Notes:
Registration fee includes admittance to course(s) of choice, course handouts, and all meals and events. One-day rates apply to registration in any one-day course. Two-day rates apply to registration in the two-day course, OR the Friday one-day course and one of the Saturday one-day courses. You may not register for one day of the two-day course.

Student Rates apply to APTA member students who are PTWA members, enrolled in a Washington state PT or PTA program, or doing affiliate work in Washington state.

Total Fees

Special Needs
Please specify dietary needs:

Please specify other accommodations:

Cancellations and Substitutions: To cancel, call the PTWA office at 360-352-7290, ext. 13. Cancellations by April 13 will receive a refund minus a $25 processing fee. Cancellations between April 13 and 23 receive a 50 percent refund. No refunds after April 23 . If there is no waiting list, substitutions will be accepted at the discretion of staff and a $25 fee will apply. We cannot accept substitutions if we have a waiting list.