Spinal Cord Injury Association of Kentucky Summit - Registration Form
Please Print, Fill-in, and Mail this Form to the address below.

Please check the appropriate payment level and complete the registration information below. Please print your name as you would like it to appear on your certificate.

REFUNDS & CANCELLATIONS: Cancellations must be received prior to September 23, 2005, minus a $10 processing fee. No refunds will be issued after this date. If a program is canceled, Organizers do not assume responsibility for any expenses other than tuition fees. Organizers reserve the right to substitute speakers, cancel or reschedule due to unforeseen events.

CONFIRMATION INFORMATION: Upon receipt of your registration, confirmation will be e-mailed to you. All areas are accessible. Please contact us at (859) 367-7189 if you require special physical arrangements to attend this meeting.

Name: ___________________________________________

Title: _____________________________________________

Address __________________________________________

City: _______________ State: _______ Zip: _____________

Organization: ______________________________________

Phone: ____________________ Fax: __________________

E-mail: ___________________________________________

$75 Professional early bird fee (before 9/23/2005)
$125 Professional regular fee (after 9/23/2005)
$20 Non-professional/Family/Individuals with Spinal Cord or Brain Injury/ Students (requires proof via student ID)

I will be attending the Pre-Conference Reception

Check enclosed and payable to:

Cardinal Hill Rehabilitation Hospital
Attn: Center of Learning
2050 Versailles Road
Lexington, KY 40504

Please fax credit card registrations to: (859) 367-7188.
Visa MasterCard American Express Other

Card #: __________________________________________

Exp. Date: _________________________________________

Name on Card: _____________________________________ (PLEASE PRINT CLEARLY)

Signature: _________________________________________