REGISTRATION FORM

Please Print (name exactly as it is to appear on badge/certificate)
Last Name 
    First Name    MI
Degree 
Address 
City 
              State    Zip Code
Telephone
(include area code)
Fax
              Email

  Fees
Prior to July 1, 2004
After July 1, 2004
Industry Representatives
$275.00
$325.00
Physicians/Dentists
$225.00
$275.00
Allied Health Professionals
$175.00
$225.00
Residents/Fellows in Training
$125.00
$150.00

Registration Includes: Syllabus, Breaks (Friday, Saturday, Sunday), Welcome Reception Friday Evening (light buffet), Continental Breakfast Saturday and Sunday, Barbecue Cook-Out/Dance Saturday Evening (full dinner), Golf Tournament (Saturday Afternoon), and Fun Run (Sunday Morning).

Yes, I will be participating in the Golf Tournament (Handicap )
Yes, I will be participating in the Fun Run

Accompanying Persons (12& older)
$100.00
$150.00
 
Names
   

(Registration Includes: Welcome Reception Friday Evening (light buffet), Continental Breakfast (Saturday and Sunday), Barbecue Cook-Out/Dance Saturday Evening (full dinner) and Fun Run Sunday morning)

[There is no charge for children under twelve but they must register and wear a badge]

Names
 

TOTAL AMOUNT ENCLOSED: $

Please print this form and make Check Payment to: BCM PM&R
and send completed form and payment (payment must accompany registration) to:
      Donna Jones
      Dept PMR
      1333 Moursund Avenue, A-221, Houston, TX 77030

For further information contact:
      Donna Jones 713-799-5086;
      e-mail: djones@bcm.tmc.edu