Treatment of Neuromuscular Diseases
May 18th,
2002
Print clearly. Fill out one form
for each person attending the lectures.
Make checks payable to KMRREC Education
__________________________________________________________________
First Name Middle Last Name Degree
__________________________________________________________________
SS# (For course registration purposes
only) Specialty
__________________________________________________________________
Home Address
__________________________________________________________________
City State Zip Code
__________________________________________________________________
Daytime Phone Number (w/area code) Fax
Number (w/ area code)
__________________________________________________________________
Hospital, University or Affiliation City/State
of Affiliation
__________________________________________________________________
List the name and age of any child that
you plan to bring to the conference.
Healthcare Professional q $70
Consumer/Family Member/Caretaker q $70
Payment: q Check Enclosed
q VISA q
MasterCard
__________________________________________________________________
Credit Card Number Exp.
Date
__________________________________________________________________
$ Amount Signature
__________________________________________________________________
Special requirements that you may have to fully participate in this program.
__________________________________________________________________
What is your primary interest? (SMA -
MD - ALS/MND or Other/Specify Above)
Return registration and tuition to: KMRREC Education
1199 Pleasant Valley Way -
West Orange, NJ 07052
Fax:
973-243-6912
For more information please
call 973-243-6813
n If you are bringing someone in a wheelchair, you will be responsible
for your own transportation.
n The recommended hotel for this conference is
The Parsippany Embassy Suites (1-973-334-1440).
They will offer a special $109/Suite rate for attendees at this
conference.
Please identify that you are attending the KMRREC Neuromuscular
Disease Course.