IPPT Conference 2022 Registration

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Complete this form for the IPPT conference registration. Each participant must register and fill out the form. If not attending the meeting, each clinic must be a registered IPPT member & pay dues to continue to be on the e-mail list and part of the Webinars and online discussions for 2022

Prefix

Dr.

Mr.

Mrs.

Miss

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First Name

Last Name

Credentials

PT, DPT

PTA

DOT

COTA

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Clinic Name

Clinic Phone Number

E-mail

Clinic Website

Relationship to clinic (Title)

Are you attending the conference ?

Yes

No- I would like a copy of the minutes

Maybe

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Fees (Clinic Dues required to be a part of Webinars throughout the year, stay on email list, receive value added discounts, and to receive minutes for conference if not attending)

Clinic Dues - $150.00 (Includes attendance to conference for 1 Owner)

Off Managers, Clinical Directors, Physical Therapist, & Owner#2- $100.00 for each additional attendee

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Payment Method

Credit Card /copy and paste PayPal.me/ippt in browser

Check (make payable to IPPT)

Send Check to Treasurer: Rick Young 200 N Poplar St, Aberdeen, NC 28315

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Submit

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