CONFERENCE REGISTRATION FORM Innovations in School-based Physical Therapy Practice

July 13-14, 2013 * Philadelphia, PA Registration Deadline: June 28

APTA Membership Number: ___________________ Name: ______________________________________________________________________ Address: ____________________________________________________________________ Daytime Phone: __________________ E-mail:_______________________________________ Agency Name (if applicable): ________________________________

Member Type Early Bird (Ends June 1)

Advance (Ends June 28)

Onsite

*Section on Pediatrics Members

$250 $300 $375

Non-Section APTA Members $325 $375 $420 Non-APTA Members $375 $425 $475 Group Rate (3 or more from same facility)

$250 $300 Not available onsite

*To join the Section on Pediatrics, visit www.apta.org and click on “Join” at the top of the page. Member registration rate applies, with transaction record. (If you are not eligible for Section membership, but would like to become a Section Partner, visit www.pediatricapta.org and click on “About the Section,” then Section Partners Program.) Payment: You can register online at www.pediatricapta.org under Quick Links/Professional Development, or you can mail your check (made payable to APTA Section on Pediatrics) with this registration form to: Component Registrar

Section on Pediatrics, APTA PO Box 327 Alexandria, VA 22313

For credit card payment, charge my: ___ MasterCard ___ Visa ___ American Express Card Number: _____________________________ Expiration Date: _____________ Signature: ____________________________________________________________ *Those paying by credit card may also fax this registration form to the Section on Pediatrics at 703/ 706-8575 or call the Component Registrar at 800/999-2782, ext 3155. Refund Policy: The Section reserves the right to cancel this event, in which case all monies paid will be reimbursed. If you need to cancel your registration, please send a request in writing to the above address by June 30, and allow 4 weeks for reimbursement (minus a $50 processing fee). No refunds will be allowed after this date.

NOTE: Attendance for this course is limited and will be handled on a first-come, first-served basis.