GREAT SEMINARS AND BOOKS REGISTRATION
Please print, fill out the registration form, and fax or mail to:

GREAT Institute
2639 Revere Drive
Akron, OH 44333-2311

Phone: 330-836-2275
Fax: 330-865-6941
Toll-Free: 877-79-GREAT
Email: GREATseminars@aol.com

Make all checks payable to: GREAT Seminars and Books, Inc.

Call GREAT Seminars and Books toll free at 877-79-GREAT with any questions.

NAME:                                                                                                                 

PROFESSION: PT PTA OT COTA (Please circle one)

HOME ADDRESS:                                                                                              

CITY:                                         STATE:           ZIP:            

HOME PHONE:                                                           

EMPLOYER/OFFICE:                                                                                         

BUSINESS PHONE:                                                           

COURSE YOU WILL BE ATTENDING:                                                            

                                                                                                                                  

LOCATION OF COURSE:                                                                                    

DATES OF COURSE:                                                           

CREDIT CARD NUMBER:                                                             EXP DATE (MO/YR):                  

NAME (as it appears on credit card):                                                           

CHECK NUMBER:                                                           

Cancellation Policy: Cancellations must be received in writing at least two weeks prior to the seminar date for a tuition refund less a $75 administration fee. No refunds will be made after this date.

Note: Registrations made within 2 weeks of the date of the seminar will incur a $75 late fee.