June 10, 2017 PEDIATRICS 101
FYSH
REGISTRATION FORM Name _________________________________ Address _____________________________________ City _________________________ State ______________________Zip _________________________ Email address ___________________________________ Phone # ______________________________ College (for students) ________________________________ (Expected year of graduation) __________
2nd Edition
FEES
□ DC
$199
□ DC ICA Member $179 □ DC ICA Pediatrics Council Member $179 □ Student $ 79 □ SICA Member $ 59
$35 additional for CE Credits ( AL, FL, GA, SC applied for) Registration: $ ________ CE credits : $ ________ TOTAL: $ ________
Payment by: □ Check □ Am Express Account # _______________________________ Exp Date _______________ CVV ____________ Cancellation policy: Registration refunded less 15% administration fee. Register by phone: 571-765-7554 By fax: 703-351-7893 or 703-528-5023 □ Visa/Mastercard
By Mail: ICA Council on Chiropractic Pediatrics 6400 Arlington Blvd, Suite 800 Falls Church, VA 22042
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