FUNCTIONAL TAPING FOR MUSCULOSKELETAL INJURIES

REGISTRATION FORM
First Name_______________________________________________
Last Name_______________________________________________
Credentials______________________________________________
Business/Clinic Name______________________________________
Address_________________________________________________
_______________________________________________
Email___________________________________________________
Phone______________________Fax_________________________
Location of Class: FIT Rehab

1 Sears Drive Paramus, NJ

Date of class: April 6th, 2013, Sat 8:00 am 8:00 pm

_________ $325.00 DC registration / $295 Student
_________ $295.00 DC / $250 Student early registration by March 15th
_________ $40.00 Additional for State CEUs NJ, NY

Form of payment:
MC/Visa #_________________________EXP__________Code______
Name on card______________________________________________
If paying by credit card, form can be faxed to (201) 945-4070
If paying by check, make check payable to Gregory Doerr, DC and mail to:
Functional Taping for MS Injuries
532 Anderson Ave
Cliffside Park, NJ 07010
You will receive a confirmation of registration, along with all class details,
upon receipt of this form and payment.

Any questions?? Email: gdoerr@bergenchiropractic.com

Call: 201-945-4075