2019 AZSCIA Push Forward Conference Registration
Please register below for the AZSCIA Push Forward Conference on Friday March 8, 2019 at:
Desert Willow Conference Center
4340 East Cotton Center Boulevard
Phoenix, Arizona 85040
8AM to 4PM

Consumers and either 1 Caregiver or 1 Family Member: Free to attend
Additional Family Members or Caregivers: $30.00
Professionals and Students: $30.00

**If you require a caregiver, please make arrangements to bring someone with you to help you during the day.
Caregivers will be able to attend all classes with you, We will not be responsible for your care.**
Thank you for understanding. We look forward to seeing you all there!
Please Pay Here: https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=9C9X7QC66LX32

First Name *
Your answer
Last Name *
Your answer
Email *
So we can send you a reminder as the day gets closer. Thank you!
Your answer
Phone Number *
In case we need to contact you. Thank you!
Your answer
Family Member
I am a :
If you are a student/professional, will you be needing CEU's? A certificate of attendance will be sent out after the conference.
I would like to be a volunteer the day of the event
Will you need any special accommodations? If so, please explain below. Thank you.
Your answer
How did you hear about the conference?
Which Rehab or Doctors office did you hear about the conference?
Your answer
Thank you for signing up for our 2019 Push Forward Conference! Please Pay Here: https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=9C9X7QC66LX32
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