2010
REGISTRATION FORM:
Please register me for: CURRENT
CONCEPTS IN WOUND HEALING™ for: (Fill in City/State
& dates) ______________________________________.
Please register me for: ADVANCED WOUND HEALING™
for: (Fill in City/State & dates) ______________________________________.
CIRCLE ONLY ONE PAYMENT TYPE
(Payment by www.paypal.com
is preferred) Using your credit card at
Pay Pal is easy!
1.) I paid by www.paypal.com Pay
to: woundseminars@sbcglobal.net
2.) A check is enclosed: Make it payable for $495.00 (FOR EACH SEMINAR)
to and mail to:
Wound Care Resources, Inc.
180 Cherry Street
Williams Bay, WI 53191-9704
I understand and agree that the seminar cost is not refundable for any
reason except that a full refund of course cost will occur if WCA cancels
a seminar for any reason under its control. Liability for refund is
limited to course cost and not for any other expense that may be incurred
by the registrant. WCA will not be held liable for any refund should
a course be interrupted by an act of God or an act of war or for circumstances
beyond its control. The materials presented in CURRENT CONCEPTS
IN WOUND HEALING™ and ADVANCED WOUND
HEALING™ by WCA and Jeffrey A. Feedar, PT, CWS®,
(Speaker) are presented for information purposes only and WCA and the
Speaker accepts no responsibility or liability for a course participant
to implement this information in any specific patient plan of care or
any other setting. Each course participant agrees they are wholly responsible
to determine the appropriateness of materials presented, for practicing
under the laws in the state and/or country in which they practice, and
for practicing within the scope of their license. Each course participant
will be required to sign a release statement on day one of the seminar
prior to the seminar beginning. No registrations will be accepted without
this form filled out (* = required field) by the registrant
and registrant's signature and agreement to these conditions.
Your signature on this registration form states that you have
read, understood, and agree to these conditions governing WCA seminars
and information presented by the Speaker.
*Name (print) ____________________________________________________________________
*Credentials (PT, PTA, RN, LPN, MD, OT, CWS®, DO, DPM, NHA, ATC,
etc.)______________
* License number(s) and State(s) (For CEU CERT.)______________________________________
________________________________________________________________________________
*Home Address (DO NOT use your work address as we register people not
facilities.)
________________________________________________________________________________
*City/Sate/Zip____________________________________________________________________
*Phone (home) (_______________)___________________________________________________
*(Very helpful!) Email______________________________________________________________
PLEASE CHECK YOUR EMAIL FOR CONFIRMATION LETTER - This is where we
will send your confirmation letter if you supply your email address!
Thank you!
*Signature_____________________________________________ *Date _____________________
Revised 4-2-2010
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Wound Care Associates
