Registration Form. Please print this form, complete it and fax or mail to OT Rehab solutions. ___ Low Vision Tampa Bay -May 3rd & 4th 2008 or November 8th & 9th 2008 (circle one) Registration Dates: Early Registration fee $350: (Two weeks prior to seminar date) Standard Registration $375: One day only $190 (indicate if attending Friday or Saturday) ___ Diabetes Tampa Bay -March 8, 2008 or January 10, 2009 (circle one) Registration Dates: Early Registration fee $185: (Two weeks prior to seminar date) Standard Registration $200: Workshop Location: Courtyard by Marriott 10152 Palm River Rd Tampa, FL 33619 (813-661-9559) Name_____________________________ Credentials_______License #:__________ Address_________________________________________________Zip____________ Contact Phone#_____________________ Fax #______________________________ E-mail_____________________________ Mail , fax, or E-mail registration with payment to: FAX: 813-672-1255 Mail: 10010 Park Place Ave Riverview, FL 33578 E-MAIL: ycate@otrehabsolutions.com WEBSITE: www.otrehabsolutions.com ___ Check enclosed #___________ (Payable to OT Rehab Solutions, LLC) ___Visa ___Amex ___Master Card Amount Authorized $________________Card #____________________________ Expiration Date_____________________ Cardholder Name___________________ Billing Address (if different from above)__________________________________ Cancellation Policy: All cancellations must be received one week before course date for a refund minus a $25 administration fee.