American Society of Hand Therapists - California Chapter

Instructions:

After you complete this form, print it out and mail along with the check or money order to:

Treasurer: Susan Clark, OTR,CHT

860 University Avenue Los Altos, Ca. 94024

Course Date: Saturday July 28th and Sunday July 29th

Location: Kaiser Union City 3555 Whipple Road

Name: As you would like it to appear on your certificate)

License #

Address: City/Sate/Zip: Home #: Work/Cell #:

Fax #: E-mail: (for confirmation)

Meal Preference

Fee: $ 150.00 payment to be postmarked no later than June 30,2007

Certificate of confirmation for 12.0 contact hours will be provided.

 
Confirmation letter and directions will be sent after receiving cheque.