Attendee Type
Non Memorial Hermann Employee
Memorial Hermann Employee
Registration Information
First Name (as it will appear on course certificate)
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Last Name (as it will appear on course certificate)
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Credentials (as will appear on course certificate)
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Email
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Verify Email
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Phone Number
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Mailing Address
Address Line 2
City
State/Province
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ON
PE
QC
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Zip
Select your discipline (click all that apply)
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OT/OTA
Other
PT/PTA
Discipline - Other
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Date of Birth (MM/DD)
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Date of Birth (MM/DD)
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Date of Birth (MM/DD)
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Professional License Number (as it will appear on course certificate)
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Professional License Number (as it will appear on course certificate)
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NABP#
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Date of Birth (MM/DD)
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Degree (as it will appear on course certificate)
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Degree (as it will appear on course certificate)
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ASHA number (as it will appear on course certificate)
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Professional License number
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Do you want to receive ASHA CEUs?
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Yes
No
Professional License Number (as it will appear on course certificate)
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Professional License Number (as it will appear on course certificate)
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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.
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I Agree
Please Acknowledge:
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I have read and understand the education credits and attendance needs for my profession as stated in the education materials.
Cancellation Policy:
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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.
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Yes
No
Would you like to receive email communications, including marketing communications, from Memorial Hermann Health System via email or text? (Text charges may apply.)
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Yes
No
Email Registration Assistance
