Personal Information

Registration Form
Part A – Core REVIEW

Company: Job Title: _ Address 1:
Address 2:

City: State:

Badge & Certificate Information Phone: ____________________________________
Please provide your name as you want it printed on your Name Badge

Please provide your name as you want it printed on your Certificate of CEU

License Number___________________________ State_____________________________________
Course Fee: $200 (USD only) (We accept only Checks)
Checks payable to: Geraci Spine & Sports Medicine (Must accompany registration form). To reserve your spot, payment must be received no later than Friday November 3, 2017. However space is limited and registration is on first come first serve basis.

Mail Payment (Check only) and Registration Form to: Geraci Spine & Sports Medicine
52 S. Union Rd Ste. 202 Williamsville, NY 14221
Name of attendee: ____________________________________________________________——–
Check Number: ——————
Cancellation Policy
Cancellation of registration must be submitted in writing via mail or email and must be postmarked or dated on or before November 3, 2017 to receive a refund less cancellation processing fee(s).
Cancellation processing fees: conference registration, $50 USD. There will be no refunds after November 10, 2017 regardless of cause.
Note: Registrations are not transferable; no substitutions can be accommodated.
Geraci Spine & Sports Medicine reserves the right to cancel, reschedule programs or change course locations due to circumstances beyond its control or close registration when programs
are oversubscribed. For these reasons, registrants are advised against purchasing nonrefundable airline tickets until they receive confirmation from Geraci Spine & Sports Medicine. Geraci
Spine & Sports Medicine is not responsible for penalties incurred as a result of cancelled transportation fares. Written, verbal or fax notice of cancellation will be given within five (5) working days of the actual date of the program whenever possible.
General Course Registration:
Registration fees include: All education sessions and handout materials, full lunch. Registration fees are designated in US currency. We accept personal checks.