Cognitive and Perceptual Evaluation - JFK Medical Center
Cognitive and Perceptual Evaluation - JFK Medical Center
Cognitive and Perceptual Evaluation - JFK Medical Center
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*Registration confirmations will be via e-mail only from: mmohary@solarishs.org<br />
Registrants are kindly requested to provide an e-mail address which they access on a regular basis. Your cooperation<br />
in printing legibly will help to ensure that you receive all registration follow-up information.<br />
CONFERENCE REGISTRATION FORM<br />
<strong>Cognitive</strong> & <strong>Perceptual</strong> <strong>Evaluation</strong>: A Function Based Approach & Adult Onset Apraxia <strong>and</strong> Unilateral Neglect Syndromes: An Overview<br />
November 5 & 6, 2011<br />
E-MAIL ADDRESS<br />
<br />
Name<br />
(Please print or type name <strong>and</strong> credentials EXACTLY as you would like it to appear on the certificate of attendance.)<br />
Mailing Address<br />
City State Zip<br />
Employer*<br />
Employer City/State<br />
Daytime Phone # Fax #<br />
Special Needs <strong>and</strong> Dietary Requests<br />
(Credentials)<br />
*If Solaris, Please Indicate Dept.<br />
Ask Supervisor to Initial <strong>and</strong> Send to: Marianne Mohary Professional Development & CME<br />
(Please Note: Registrations will not be processed without approval)<br />
Please Check Choice(s): √ Early Bird Regular<br />
____ COGNITIVE AND PERCEPTUAL EVALUATION: A FUNCTION BASED APPROACH & ADULT ONSET<br />
APRAXIA AND UNILATERAL NEGLECT SYNDROMES: AN OVERVIEW<br />
Sat. & Sun. / November 5 & 6, 2011<br />
____<br />
(By 10/6/11)<br />
$415 $435<br />
ADDITIONAL UPCOMING COURSES/CONFERENCES – FALL, 2011 Early Bird Regular<br />
MAXIMIZING FUNCTION AND PARTICIPATION IN OLDER ADULTS: CLINICAL, CAREGIVER AND<br />
HOME INTERVENTIONS (Course Instructor: Claire M. Mulry, MSOT, OTR, CAPS)<br />
Sat. / November 19, 2011<br />
(By10/20/11)<br />
$135 $145<br />
COURSES IN NEUROLOGICAL MANAGEMENT & REHABILITATION . . . 2011<br />
Please Check One: Early Bird Regular<br />
OPTION I FRIDAY, DECEMBER 2, 2011 (ONLY)<br />
Clinical Neuroscience for Practitioners: Evidence-Based Approaches to Diagnosing & Managing Neurological Disorders<br />
(By 11/3/11)<br />
$155 $175<br />
OPTION II SATURDAY, DECEMBER 3, 2011 (ONLY)<br />
Stroke Management & Rehabilitation: Critical Aspects for Practitioners $155 $175<br />
OPTION III TWO COURSE SPECIAL RATE: DECEMBER 2 AND DECEMBER 3, 2011<br />
Clinical Neuroscience for Practitioners: Evidence-Based Approaches to Diagnosing & Managing Neurological Disorders<br />
AND Stroke Management & Rehabilitation: Critical Aspects for Practitioners<br />
$275<br />
(Save $35)<br />
$295<br />
(Save $55)<br />
If discount applies • Percent Discounted_______ %<br />
Dollar amount of Discount $ _______<br />
TOTAL PRICE (After subtracting discount) $ _______<br />
Method of Payment: Check Check #:<br />
Credit Card #:<br />
Three digit security code on back of credit card<br />
Credit Card / Cards we accept: Visa MasterCard<br />
Exp. Date<br />
First three digits of billing address for card<br />
Credit Card Authorization (Please sign)<br />
Enclosed Tuition Fee: $<br />
PLEASE MAKE CHECKS PAYABLE TO: <strong>JFK</strong> MEDICAL CENTER<br />
AND MAIL TO:<br />
MARIANNE MOHARY / PROFESSIONAL DEVELOPMENT & CME<br />
<strong>JFK</strong> JOHNSON REHABILITATION INSTITUTE<br />
65 JAMES STREET / EDISON, NJ 08818<br />
PHONE: 732-632-1570 • FAX: 732-767-2967 • E-MAIL: mmohary@solarishs.org
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