2017 Conference Registration – Mail In Payment

2017 Annual Conference Registration- Mail In Payment

First Name *

Last Name *

Title *

License#/Credential

Organization Name *

Street Address *

City *

State *

Zip Code *

Work Phone *

Email *

*Photo Release

By registering for and/or attending the 2017 Conference, I understand that publicity, photographs and/or videos may be taken during the event and my likeness may appear in these images. I hereby give permission that photos and/or videos containing my likeness may be used for publicity or general information purposes including, but not limited to, publication on the CCR website or other publicity, whether in print or electronic mediums, which may be seen by the general public.

Please check the appropriate box below. *

I agree

I disagree

End Section

Click on the SUBMIT button to complete your conference registration. Make checks payable to: Center for Cognition and Recovery. Mail your payment to: 3659 S. Green Road, Suite 315, Beachwood, Ohio 44122. Mail your payment of $100 to:

End Section

2017 Conference Registration – Mail In Payment

*Photo Release

Click on the SUBMIT button to complete your conference registration. Make checks payable to: Center for Cognition and Recovery. Mail your payment to: 3659 S. Green Road, Suite 315, Beachwood, Ohio 44122. Mail your payment of $100 to:

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