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Printable Course Registration Form |
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| Registration by mail: Complete the
registration form and mail with your check, money order, or credit card
number to: Recovering Function 1582 Pam Lane San Jose, CA 95120-5707 (408) 268-3691 info@recoveringfunction.com Make checks or money orders payable to Recovering Function. Registration by fax: Complete the registration form and fax with your credit card number to: Recovering Function at (408) 927-6183. |
| Please fill out this form completely and PRINT clearly or processing of your registration may be delayed. Copies of this registration form are also accepted. Please use a separate form for each registrant. |
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| If you are responding to a mailing, please enter the complete code from your mailing label _________________________ |
| Course or package: ___________________________________________________________ |
| Course location: ____________________________________ |
| Course dates: _____________________________________ |
| Participant information |
| Please specify your name and credential as you would like them to appear on your certificate. |
| Name: _________________________________________________ |
| Credential: _________________ (e.g. OTR/L, MPT) |
| Nickname for name tag: _________________ |
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| E-mail: _____________________________ |
| Home phone: _________________________ |
| Work phone: _________________________ |
| Work Fax: ___________________________ |
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| Country: ____________________________ |
| Address information below to be completed by United States registrants only: |
| Home address: _______________________________________ |
| City: ______________________ State:______ Zip:___________ |
| Facility name : _________________________________________ |
| Street: __________________________________________ |
| City: _________________________ State:______ Zip:___________ |
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| How did you first hear about this course?: __________________________ |
| Previous NDT courses taken/dates/instructors _______________________ |
| __________________________________________________________ |
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| Payment enclosed: ________________ |
| Credit card #: ___________________________________ |
| Visa MC AmEx Disc Exp date: ______________ |
| For group registrations please indicate the size of your group and list the names of the other group members: |
| Size of group:______ |
| Names: ___________________________________________ |
| ___________________________________________________ |
| Group registration policy: All group members must be from the same facility and registering for the same course or package (therapists must register at the same time, but may choose different course dates). |
| Course cancellation policy:
Cancellations must be received in writing 14 days or more before the course begins to receive a refund (minus $50 processing fee). Otherwise you will receive a 75% credit toward a future course or package sponsored by Recovering Function. |
| Group cancellation policy:
Group registrations are non-refundable. If you cancel, you will receive a 75% credit toward a future Recovering Function course or package. |