Physical Therapy As Your Future - University of Iowa Carver College

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Registration fee is $20 per person
and incudes lunch.
Name___________________________________________________
Payment:
Address_________________________________________________
□ Enclosed is my check payable to
Physical Therapy & Rehabilitation Science
Email (to receive confirmation)_______________________________
School Attending__________________________________________
Academic Major (college students only)________________________
□ Enclosed is cash
□ Charge my:
□ Visa □ Mastercard □ Discover
in the amount of $___________
I AM A (Check the appropriate choice) *
Student:
□
□
High School
Card Number________________________
College
V#_______ Expiration Date ____________
Year:
Advisor:
□ Freshman □ Sophomore
□ Junior □ Senior □ Graduate
□ High School □ College
* The University of Iowa requests this information for the purpose of processing your registration
for this conference. No persons outside the University are routinely provided this information.
PROGRAM COORDINATORS: Byron Bork, Kelly Sass & Carol Leigh
Department of Physical Therapy & Rehabilitation Science
The University of Iowa
1-252 Medical Education Building
Iowa City IA 52242-1190
PH: 319/335-9792 FAX: 319/335-9707
www.medicine.uiowa.edu/pt
Individuals with disabilities are encouraged to attend all University of Iowa sponsored events. If
you are a person with a disability who requires an accommodation to participate in this
conference, please contact the Department of Physical Therapy & Rehabilitation Science in
advance at 319-335-9792. The University of Iowa prohibits discrimination in employment,
education programs, and activities on the basis of race, national origin, color, creed, religion, sex,
age, disability, veteran status, sexual orientation, gender identity, or associational preference. The
University also affirms its commitment to providing equal opportunities and equal access to
University facilities. For additional information on nondiscrimination policies, contact the Office of
Equal Opportunity and Diversity, (319) 335-0705 (voice) and (319) 335-0697 (text), 202 Jessup
Hall, The University of Iowa, Iowa City, Iowa 52242-1316.
Cardholder’s Name
___________________________________
Cardholder’s Billing Address
___________________________________
Signature ___________________________
MAIL REGISTRATION TO:
Physical Therapy & Rehabilitation Sciences
The University of Iowa
1-252 Medical Education Building
Iowa City IA 52242-1190
FAX TO: 319/335-9707
EMAIL TO: carol-l[email protected] The Doctor of Physical Therapy Program at the University of Iowa is accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE),
1111 North Fairfax Street, Alexandria, Virginia 22314; telephone: 703-706-3245; email: [email protected] website: www.capteonline.org.