September 2, 2010 International Chiropractors Association
 
Chiropractors

Colorado Pediatrics Conference
November 20-22, 2009 - The Broadmoor, Colorado Springs, Colorado



If you prefer to fill out and mail in a form, please click here for printable version.



 
First Registrant First Name*
        Last Name
Second Registrant First Name*
        Last Name
Email Address*
Website Address
Home Address
City
State/Province
Postal Code (Zip)
Country
Chiropractic College (for students)
Expected month/year of graduation
Home Phone
 ( )
Cell Phone
 ( )

REGISTRATION FEES

If you wish to become a member of the Pediatrics Council or ICA and take advantage of the
lowest registration rate call 1-800-423-4690 or 703-528-5000.

Check all that apply: Peds Council Member ICA Member Non-Member SICA Member Student CA Guest

Save $100! Register by November 5!

Registrations received either by fax, online or mail after October 5 will automatically be charged the higher rate.
If you have a ChiroSecure discount certificate you must submit ORIGINAL certificate
  Advance Registration
By November 5		 After
November 5
Pediatrics Council Member/ICA Member DC $379 $479
Non-Member DC $429 $529
SICA member $179 $279
Student $209 $309
1st year ICA Member DC $299 $399
CA/Guest (Non-DC) $259 $359

Registration includes license renewal credits in approved states.
PAYMENT INFORMATION
Total Amount to be Charged (PLEASE FILL IN)
CREDIT CARD INFORMATION
Please charge my:* VISA
MasterCard
American Express
Discover
Credit Card #*
Exp. Date*

Security Code (3 numbers on the back of the card)

* For verification purposes, please type in the numbers and letters that you see below then press the Submit button