Registration Form
IJCAHPO ' s 49 th Annual Continuing Education Program
Registrations / Cancellations MUST be received on or before the following dates :
• On-Site Program Changes / Cancellations / Refunds : October 22
• On-Demand Registration / Changes Deadline : November 19 , 12 pm CT
REGISTRANT INFORMATION
Please list your credentials Date of Birth ( mm / dd / yy ) / /
Name � Ms . � Mrs . � Mr . ( )
First M . I . Last Former name , if applicable Home Address City Province / State Zip Country
Preferred Telephone - - Preferred Email Address
IN CASE OF EMERGENCY , PLEASE NOTIFY - - Name
Telephone Number
Which category best describes your professional activities ? ( Check all that apply ) |
� Administration / Management |
� Contact Lenses |
� Nursing |
� Scribe |
|
� Clinical Research |
� Front Office |
� Ophthalmic Photography |
� Student |
|
� Clinical / Diagnostic Testing |
� Laser Technology |
� Optical |
� Surgical Assisting |
|
� Coding Specialist |
� Low Vision |
� Orthoptics |
� Surgical Coordinator |
� Other _________________________ |
Number of years worked in ophthalmology
EMPLOYER INFORMATION
Name of Practice
Number of years with current employer
Business Address City Province / State Zip Country
Business Telephone - - Ext . Fax Number - -
Employer ’ s Practice Emphasis ( Check all that apply ) |
� Cataract / IOL |
� Glaucoma |
� Ophthalmic Pathology |
� Refractive Surgery |
� Comprehensive Ophthalmology |
� Low Vision |
� Optical Dispensing |
� Retina / Vitreous Disease |
� Contact Lens |
� Neuro-Ophthalmology |
� Pediatric Ophthalmology / Strabismus |
� Other ___________________________ |
� Cornea / External Disease |
� Oculoplastic / Reconstructive Surgery |
METHOD OF PAYMENT Registrations received without payment will NOT be processed . � Check � Money Order � VISA � MasterCard � Discover � American Express
If paying by check or money order , please make payable to IJCAHPO . Checks must be in U . S . dollars ( USD ). If paying with a credit card , please complete the information below . A $ 50 fee will be assessed for declined checks and declined credit cards .
Card # Expiration Date / Security Code
Payer ’ s Name ( Please PRINT )
Payer ’ s Billing Address City Province / State Zip Country
Authorized Signature X
Check Preferred Address � Home � Work
� Special accommodations : IJCAHPO provides reasonable and appropriate accommodations on-site at the program venue to individuals with documented disabilities who demonstrate a need for special accommodations . Specific special accommodations should be related to functional limitations . Please include additional supporting documentation from the medical professional who diagnosed the condition . It is essential that the documentation of the disability provides a clear explanation of the current functional limitation ( s ) and a rationale for the requested accommodation . For more information contact us at 800-284-3937 .
Type or print clearly . Use one form per registrant . Duplicate this form for additional registrants .
IJCAHPO ID # Government Facility / Duty Location
IJCAHPO reserves the right to adjust registration charges originally paid with a credit card via fax , mail or internet if the amount originally paid was deficient or excessive . The credit card account will be charged or credited and the cardholder will be provided with a notice of the adjustment .
Please indicate registration selections on reverse side .
• Send registration form with payment to : IJCAHPO , 2025 Woodlane Drive , St . Paul , MN 55125-2998
• Fax : 651-731-0410 Questions ? 800-284-3937 . To avoid duplication , do not mail and fax registrations .
November 12-14 , 2021 • Hilton New Orleans Riverside 9
General Information General Information