APMA REGION ONE/PODIATRY INSTITUTE CONFERENCE REGISTRATION FORM
Please fill out one form per DPM registrant. Type in information before the tab or arrow.
Practice Name Phone Fax
Address City State Zip
Doctors' Program Registration
Doctors Scientific Program includes continental breakfast daily and lunch Friday and Saturday. CPR Workshop includes dinner.
Name First name for badge Email
General Registration
___ $395 for APMA members from New England registering before September 30; $450 after September 30
___ $495 for APMA Members from outside New England registering before September 30; $550 after September 30
___ $695 for non-APMA Members
___ $95 for Residents
___ $265 for Retired or Military
___ $60 for CPR Friday, 6:45 to 8:30 pm
Free Workshop Sign-ups – Space is Limited – First Come, First Served
Friday Concurrent Workshops, 11:00 am to 12:00 pm. Choose one of three.
___ Equinus and PTTD Surgical Solutions
___ The Application of Bone Anchors for Tendon and Ligament Pathology
___ Advanced Wound Care/Dermagraft
Friday Concurrent Workshops, 12:00 to 1:00 pm. Choose one of three.
___ Equinus and PTTD Surgical Solutions
___ The Application of Bone Anchors for Tendon and Ligament Pathology
___ Advanced Wound Care/Dermagraft
Sunday Concurrent Workshop, 10:00 am to 12:30 pm
___ Biomechanics, DME and Orthotics
$_____ Total DPM Registration Fees
Assistants' Program Registration. Please send information for additional staff people on separate page.
Assistants Program includes continental breakfast and lunch on Friday. CPR Workshop includes dinner.
Name First name for badge Email
___ $60 per person for APMA member staff ___ $260 per person for non-APMA member staff ___ $60 for CPR Friday, 6:45 to 8:30 pm
Name First name for badge Email
___ $60 per person for APMA member staff ___ $260 per person for non-APMA member staff ___ $60 for CPR Friday, 6:45 to 8:30 pm
$___ Total Assistant Registration Fees
Payment Information
Check enclosed for $ Make payable to APMA Region One Conference.
Process $ on credit card (Visa or MasterCard only)
Visa or MasterCard Number Expires
Name on card
Mail registration form with check to:
APMA Region One Conference
10 Maple Street, Suite 301, Middleton, MA 01949
Or fax with credit card to 978-646-9673.