Attendee Type
Please select an attendee type.
Non Memorial Hermann Employee
Memorial Hermann Employee
(If so, you must register with your Memorial Hermann E-mail address)
Registration Information
First Name (as it will appear on course certificate)
*
Last Name (as it will appear on course certificate)
*
Credentials (as it will appear on course certificate)
*
Email
*
Verify Email
*
Phone Number
*
Mailing Address
*
Address Line 2
City
*
State/Province
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AA
AE
AP
AS
FM
GU
MH
MP
PR
PW
VI
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Zip
*
Country
*
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo (the Democratic Republic of the)
Congo (the)
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Federated States of Micronesia
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong SAR, PRC
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (the Democratic People's Republic of)
Korea (the Republic of)
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau SAR, PRC
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Martin
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia / South Sandwich Islands
Spain
Sri Lanka
St. Lucia
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan (the)
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan (Province of China)
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Wallis and Futuna Islands
Western Sahara
Yemen
Zambia
Emergency Contact Name
Emergency Contact Number
Select your discipline (click all that apply)
*
OT/OTA
Other
PT/PTA
SLP
Date of Birth (MM/DD)
*
Date of Birth (MM/DD)
*
Date of Birth (MM/DD)
*
Discipline - Other
*
Professional License Number (as it will appear on course certificate)
*
Professional License Number (as it will appear on course certificate)
*
ASHA number (as it will appear on course certificate)
*
Professional License number
*
Do you want to receive ASHA CEUs?
*
Yes
No
Degree (as it will appear on course certificate)
*
Degree (as it will appear on course certificate)
*
NABP#
*
Date of Birth (MM/DD)
*
Professional License Number (as it will appear on course certificate)
*
Professional License Number (as it will appear on course certificate)
*
Employer Location
*
Katy Rehab Inpatient
Katy Rehab Outpatient
MH Home Health
MH Southeast
MH Southwest
MH TMC
Non-MHHS
Other MHHS Location
SM&R Location
TIRR (Medical Center)
TIRR Challenge, Kirby Glen
TIRR Challenge, The Woodlands
TIRR Greater Heights
TIRR Kirby Glen
TIRR Memorial City
TIRR Southeast
TIRR Sugarland
TIRR Woodlands OP
TIRR Woodlands, IP
Special Dietary needs
Please comment if you require any assistance, needs or accommodations:
In consideration for the opportunity to participate in this event, I agree to RELEASE, DISCHARGE AND AQUIT FOREVER the Memorial Hermann Health System, its subsidiaries, its respective officers, directors, agents, members, and employees from any and all liabilities, claims, causes of action, costs and expenses (including, but not limited to, court costs, penalties, attorneys' fees and disbursements, and amounts paid in settlement) of any kind or character whatsoever, arising out of or relating to my participation. This release includes, but is not limited to, all claims under any state, federal, or local law or regulation and all claims at common law, including without limitation negligence and tort claims, and all claims for damages, exemplary and punitive damages, costs, and attorneys' fees.
*
I Agree
Please Acknowledge:
*
I have read and understand the education credits and attendance needs for my profession as stated in the education materials.
Cancellation Policy:
*
I have read and understand the cancellation policy as stated in the course materials.
Do you allow Memorial Hermann to share this specific information with associated course instructor and/or associated group affiliated with this course or conference.
*
Yes
No
Receive email communications, including marketing communications, from Memorial Hermann Health System via email or text. (Text charges may apply.)
*
Yes
No
How did you hear about this course? You may select more than one answer.
Email
AOTA
LinkedIn
APTA
Facebook
Colleague
TIRR Journal
Other
Email Registration Assistance