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REGISTRATION FORM

2014R321

24th Annual Mayo Clinic Symposium on Sports Medicine

November 7-8, 2014 • Kahler Grand Hotel, Rochester, MN

Mail form and payment to: Mayo School of Continuous Professional Development Plummer 2-60 200 First Street SW Rochester, MN 55905

Phone: FAX: E-mail: Web site:

800-323-2688 or 507-284-2509 507-284-0532 cme@mayo.edu www.mayo.edu/cme

Register on-line at: www.mayo.edu/cme/sportsmed

Contact Information Name of Registrant – first name, middle name or initial, and last name

Degree – select all that apply

Name of Institution

MD DO PT Other - specify Medical Specialty

ATC

Preferred Mailing Address – select one Work/Business Address – street address

Work/Business

Home

Work Phone – include all country and city/area codes as needed along with complete phone number

City

State or Province

ZIP or Postal Code

Country

Home Address – street address

Home Phone – include all country and city/area codes as needed along with complete phone number

City

State or Province

ZIP or Postal Code

Country

E-mail Address

FAX – include all country and city/area codes as needed along with complete phone number

FAX Location – select one Work/Business Home

SPECIAL NEEDS

If you have special assistance needs or dietary restrictions, describe here:

Registration Fee: Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 425 Athletic Trainers, Physical Therapists, Fellows, Residents, Nurses . . . . . . . . . $ 325

$ ________ $ ________

Total Payment Enclosed I plan to attend the course reception on Friday, November 7 at the DAHLC.

$ ________

BOC Physical Therapy

Registration Type of credit that you are interested in receiving:

AMA/Category 1AAFP

Payment Information* - (US funds only * Wire transfers will be assessed a $25 USD fee. ) Check is enclosed in the amount shown at right – make checks payable to Mayo Clinic

Payment Total

Credit Card – select one Discover MasterCard

Visa

Account Number

Exp Date – mm/yy

Name of Cardholder – as it appears on the card

Signature of Cardholder – required X

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