"Gait Theory and Practice" Registration
Please read the following information and submit the form to register for this Mission Gait course hosted by the Tidewater District of the VPTA.

Sat. and Sun., June 2-3, 2018, at Pivot Physical Therapy (Oyster Point location)
751 J Clyde Morris Blvd, Newport News, VA 23601

Space is limited to the first 50 registrants. Your reserved seat in the course will be confirmed via e-mail once payment (check or money order) has been received via mail. Instructions will be provided on the form submission page.

Course materials will be printed and provided the weekend of the course.

Coffee, water, bagels, and fruit will be provided both mornings of the course.

Lunch options:
1. "on my own" - grab a bite at a local restaurant of your choice during the 1 hour lunch break
2. "bring my own" - brown bag it! limited refrigerator space + microwave available on site
3. "bring it to me" - we will have the option to order in boxed lunch each day at an additional cost (restaurants and prices TBD closer to course date)

VPTA/APTA Members: $300
Non-Members: $400
All "Early Birds" save $50 regardless of membership status!
Early registration ends May 4, 2018.
Registration deadline is May 25, 2018.

Course Policies:
https://docs.google.com/document/d/1yEtBNfSLa-3c9nz8Fgivyp3-gUYcTgRfqo9n_y21mUU/edit?usp=sharing

Course Flyer
https://drive.google.com/file/d/1Bxbw-4Bco1vzClmC4qbn5kBKFEsR3VF3/view?usp=sharing

Course Brochure
https://drive.google.com/file/d/1Z4LppC5X2oaaSagBof9nTSbS0tzeufq4/view?usp=sharing

Email address *
Discipline *
First Name *
Your answer
Last Name *
Your answer
Please provide APTA membership number to qualify for a discounted registration rate. *
Your answer
Telephone Number e.g. (123) 456-7890 *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Method of Payment *
Personal checks and money orders are the accepted methods of payment. All checks should be made payable to "Tidewater Physical Therapy Association" and mailed to the address provided on the confirmation page (visible once you submit this form).
Lunch Selection *
Special Requests
Seating needs, educational accommodations, dietary restrictions, lodging recommendations, etc.
Your answer
Please check the following box to verify that you have read and agreed to the Course Policies. *
Required
A copy of your responses will be emailed to the address you provided.
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