Clone of RUNNING REHAB SPECIALIST

ADVANCED CLINICAL MANAGEMENT

This registration is for participation in an ACM course as a non Fellow in Training. Each ACM course is approved for 16 CCUs by the Texas Physical Therapy Association.
NAME

First NameMiddle NameLast Name
PROFESSIONAL CREDENTIAL(s)
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
EMAIL (personal email recommended)
PHONE NUMBER

Area CodePhone Number
EMPLOYER / SCHOOL
OCCUPATION / CREDENTIALS
YEARS OF CLINICAL PRACTICE
REFERRAL SOURCE

Other
IF REFERRED BY IAR FACULTY / STUDENT, PLEASE IDENTIFY THIS INDIVIDUAL
PLEASE INDICATE WHICH ACM LEVEL, LOCATION, & DATE OF YOUR PREFERRED COURSE.
Additional Comments
Cancellation & Refund Policy

Participant/group is eligible for a full refund minus 25% of administrative fees if participant/group cancels 30 days prior to the course date. Participant/group is not eligible for a refund if participant/group cancels less than 30 days prior to the course date. Participant/group is eligible to transfer all course fees to any future courses in a specific time frame. Participants/groups will receive a full transfer to another course or full refund if the course is canceled by the program.
PLEASE COMPLETE PAYMENT TO CONFIRM PARTICIPATION IN THE COURSE

ACM 1

$975.00 Quantity

ACM 2

$975.00 Quantity

ACM 3

$975.00 Quantity

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Total

Debit or Credit Card

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ADVANCED CLINICAL MANAGEMENT