Placing the Hand in Space - Secure Registration Form

 

  Course Registration Form
Placing the Hand in Space
Reconstructive Surgery of the Shoulder, Elbow and Wrist
After submitting this page you will be transferred to a secure SSL order form to enter your credit card information.
Note: * denotes required fields
*Name:
Please type your name as it should appear on the certificate, including credentials:
First
 		Last
Company:
Credentials:
*Mailing Address: E-mail address:
Address Line 2: Confirm E-mail address:
*City:    *Work Phone / Ext:  /
*State/Province, Zip:   Fax No.
Country: Home Phone:
    Last 4 Digits of Credit Card:

 

 

Please indicate current professional title:
Military
DO
General Surgeon
Hand Surgeon
MD
Orthopedic Surgeon
Plastic Surgeon
Hand Fellow
Resident
Allied Health Professional

 

Other Events
Donations Yes! I would like to make a donation to Hand Rehabilitation Foundation in the amount of $
Please indicate need of any special accommodation:

 

Registration Fees: Submitted on or before 2/12/2010: After 2/12/2010:
Allied Health Professional $775.00 $775.00
Fellow / Resident (Must include letter from chief of service) $595.00 $595.00
Surgeon / Physician $925.00 $925.00
Military $595.00 $595.00
Refund Policy:  Registration fee less $75.00 cancellation fee will refunded if written notification received prior to February 12, 2010.  No refunds after February 12, 2010.
Hand Rehabilitation Foundation
700 S. Henderson Rd., Suite 100
King of Prussia, PA 19406
Phone: 610.768.5958
Fax: 610.768.8887
E-mail: hrf@handfoundation.org
Thank you! Please check here before submitting this form to indicate your acceptance of the fees and refund policy listed above.