Conference Registration Form

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Conference Registraton Form

Registration Form

First Name

Last Name

Prefix

Suffix

Email

Phone

Address line 1

Address line 2

City

State

Zip Code

Country

Profession *

MD

DO

PhD

Nurse

Nurse Practitioner

Physician Assistant

DPM

Occupational Therapist

Physical Therapist

Social Worker

Student

Other

Degree/Credential

Specialty

Any comments/special accommodation and needs we should be aware of?

How did you hear about these workshops?

I have read and agree to the registration terms and condtions, and cancellation policy.

You will receive a welcome mail within 24 to 48 hours after submitting this form and paying the registration fee. If you do not get the email, please contact us.

Thanks for submitting!

We will email you within 24 to 48 hours.

Follow us on

Email: care@mecfsclinicmn.org

Phone: 612-440-9699

Fax: 833-941-4900

Address: PO Box 26361, St Louis Park, MN 55426

Tax ID (EIN): 88-2948473

We are a 501(c)(3) charity organization

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