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www.ACRM.org Questions? Looking for help? Please call +1.703.435.5335 or MemberServices@ACRM.orgREG FORM PG 1
MS MR
REGISTRATION DATE
REGISTER online at www.ACRM.org/register OR complete this form and submit via email, fax or mail (see last page).
>
¨ First-time attendee
¨ ACRM is grateful for the generous support of our Conference"Sponsors and Exhibitors and plans to introduce attendees to"thevalue they offer via a small number of informative emails"prior tothe conference. Check here to opt-out of these emails.
CONTACT INFORMATION
REGISTRATION OPTIONSThere are 3 routes to register:
1) 6-Day World Pass2) CORE & more3) Instructional Course Pass
WHAT SESSION(S) WILL YOU BE PRESENTING? (Select all that apply)
I am not presenting this year SymposiumPoster Oral Paper Instructional Course (Pre-Conference)Early Career Development Course (Pre-Conference) Leadership Development Course (Pre-Conference) Plenary or Special Symposium LaunchPad
>
ATTENDEE TYPE (Select One) Consumer Member Early Career Member Professional MemberStudent/Resident/Fellow Member
ACRM COMMUNITY GROUPS
CORE: 26 – 29 SEPT 2021 PRE-CONFERENCE: 24 – 26 SEPT I N T E R D I S C I P L I N A R YACRM 98th Annual Conference
PROGRESS IN REHABILITATION RESEARCH #ACRM2021
> Are you attending any COMMUNITY GROUP MEETINGS?
Yes
>
Consumer Non-Member Early Career Non-Member Professional Non-MemberStudent/Resident/Fellow Non-Member
Non-member registration includes 6-month introductory ACRM membership.
Please select the ACRM groups that are most relevant to you, so we may introduce you to opportunities and benefits available.
You will receive email communication for the groups that you select. You may opt out of these emails anytime.
Aging Research & Geriatric Rehabilitation Networking Group
Arts & Neuroscience Networking Group
Athlete Development & Sports Rehabilitation Networking Group Behavioral Health Group (New Forming)
Brain Injury Interdisciplinary Special Interest Group (BI-ISIG)
Cancer Rehabilitation Networking Group
Career Development Networking GroupComplementary, Integrative Rehabilitation Medicine Networking Group Health Services Research Networking GroupInternational Networking Group
Lifestyle Medicine Networking Group
Limb Care Networking Group
Measurement Interdisciplinary Special Interest Group (M-ISIG)
Military / Veterans Affairs Networking Group
Neurodegenerative Diseases Networking Group
Neuroplasticity Networking Group
Pain Rehabilitation Networking Group
Pediatric Rehabilitation Networking Group
Physicians and Clinicians Networking Group
Rehabilitation Treatment Specification Networking Group
Spinal Cord Injury Interdisciplinary Special Interest Group (ISIG)Stroke Interdisciplinary Special Interest Group (ISIG)Technology Networking Group
Please make your selections on the following pages >>
EARLY BIRD
DR PROF
First Name
Zip/Postal Code
Last Name
Credential (degrees)
Title
Organization
Mailing Address line 1
Mailing Address line 2
City, State
Country
Phone
Emergency Contact Name
Emergency Contact Phone
No
www.ACRM.org Questions? Looking for help? Please call +1.703.435.5335 or MemberServices@ACRM.orgREG FORM PG 2
Please check the boxes for all activities you wish to include in your WORLD PASS
3.5 DAY CORE PASS
6-DAYWORLD PASS
WORLD PASS
PURCHASERSPlease check the boxes for all activities you
wish to add on in your WORLD PASS purchase
$399 - 579 $599 - 779(Prices in parenthesis below indicate the Early Bird costs if purchased separately.)
CORE CONFERENCE ($349/one-day student - $579/3.5 day professional) Educational Symposia SUN – WED: 300+ sessions & lectures 4 Plenary Sessions Moderated Panel Discussions Awards Lectures Scientific Posters — hundreds! ACRM Community Group Meetings: Interdisciplinary Special Interest Groups (ISIGs), Networking Groups, Task Forces and Committees. A few are invitation only. 400+CME/CEU credits
VIRTUAL ACRM EXPO: Poster Grand Rounds Live Video Chats with vendors Learning Center
PRE-CONFERENCE
INSTRUCTIONAL COURSES ($169 - 279) additional fee Early Career Development Course: SUN ($349 - 499) additional fee
Conference Slides / PDFs Digital access to all available symposia and pre-conference instructional course slide presentations (PDFs). A few content leaders elect not to have their slides available to attendees, therefore some sessions may not be included. Cognitive Rehabilitation Training and Early Career Development Course are not included.
3.5 days of sessions
6-days of sessions
PASS COMPARISON
I N T E R D I S C I P L I N A R YACRM 98th Annual ConferencePROGRESS IN REHABILITATION RESEARCH #ACRM2021
CORE: 26 – 29 SEPT 2021 PRE-CONFERENCE: 24 – 26 SEPT
Leadership Development Course: SUN ($349 - 499) additional fee
www.ACRM.org Questions? Looking for help? Please call +1.703.435.5335 or MemberServices@ACRM.orgREG FORM PG 3
STUDENT / RESIDENT / FELLOW CONSUMER / NON-PROFESSIONAL CAREGIVER
PAID MEMBER 599 749 849
NON-MEMBER 699 849 949
EARLY CAREERPAID MEMBER 699 849 949
NON-MEMBER 799 949 1,049
PROFESSIONALPAID MEMBER 779 949 1,349
NON-MEMBER 879 1,049 1,449
BEST VALUE
CORE + PRE-CONFERENCEINCLUDES: VIRTUAL ACCESS to all CORE Conference sessions including symposia, plenaries, featured sessions, awards lectures, ACRM Community Group Meetings, poster and papers, PLUS all Pre-Conference courses (40+), CME/CEUs credits, and full access to actionin the ACRM Virtual EXPO.
WO
RLD
PA
SS
6-D
AY
WORLD PASS6-DAY
STUDENT / RESIDENT / FELLOWCONSUMER / NON-PROFESSIONAL CAREGIVER
PAID MEMBER
NON-MEMBER
EARLY CAREERPAID MEMBER
NON-MEMBER
PROFESSIONALPAID MEMBER
NON-MEMBER
SUN 2:10 PM THROUGH WED 26 - 29 SEPT3.5
DAY
3.5-DAY CORE PASS
I N T E R D I S C I P L I N A R YACRM 98th Annual ConferencePROGRESS IN REHABILITATION RESEARCH #ACRM2021
INCLUDES: VIRTUAL-ONLY access to all sessions SUN afternoon through WED including symposia, plenaries, featured sessions, awards lectures, ACRM community group meetings, posters, CME/CEU credits, and full access tothe ACRM VIRTUAL EXPO. & Learning Center including
CORE: 26 – 29 SEPT 2021 PRE-CONFERENCE: 24 – 26 SEPT
ON-SITE
399449529629
579679
499549649749729829
599649849949
1,1491,299
STUDENT / RESIDENT / FELLOW CONSUMER / NON-PROFESSIONAL CAREGIVER
PAID MEMBER 349 409 489NON-MEMBER 399 469 589
EARLY CAREERPAID MEMBER 389 449 519NON-MEMBER 469 549 619
PROFESSIONALPAID MEMBER 429 499 549NON-MEMBER 499 579 649
1-DA
Y
Select SUN AFTERNOON MON, TUES, or WED INCLUDES: ONE day of VIRTUAL access to all sessions scheduled on the day selected, CME/CEU credits, and full access to action in the ACRM Virtual EXPO.
1-DAY CORE PASS
CME/CEU processing is included with registration. Please select all that you will be claiming:○ ABCOP (limb loss) (new as of 2021)○ Case Managers (CCMC)○ Dietitians (CDR)○ Disability Management Specialists (CDMS
Commission)○ Health Care Executives (ACHE)
○ Nurses (ANCC)○ Occupational Therapists (AOTA)○ Physicians (ACCME, includes Canada Physicians
and Physician Assistants)○ Psychologists (APA Division 22 Accreditation)○ Rehabilitative Counselors (CRCC)
○ Social Workers (NASW)○ Speech-Language Professionals (ASHA)○ Physical Therapists (FSBPT and remaining
individual States approvals)○ Massage and Body Works (NCBTMB)
SELECT ONE: SUN MON TUES or WED
EARLY BIRD REGULAR ON-SITE
CLICK HERE for the latest deadlines
CLICK HERE for the latest deadlines
CLICK HERE for the latest deadlines
ONSITEEARLY BIRD REGULAR
REGULAREARLY BIRD
www.ACRM.org Questions? Looking for help? Please call +1.703.435.5335 or MemberServices@ACRM.orgREG FORM PG 4
I N T E R D I S C I P L I N A R YACRM 98th Annual ConferencePROGRESS IN REHABILITATION RESEARCH #ACRM2021
INSTRUCTIONAL COURSE PASS (PRE-CONFERENCE)
EARLY BIRD REGULAR ON-SITE
PAID MEMBER 169 199NON-MEMBER 199
PAID MEMBER 229 269 319NON-MEMBER 319 389
Choose from dozens of half-day and full-day courses on a wide variety of topics — see next page. All Instructional Courses are INCLUDED in the WORLD PASS.
4-HOUR
4-HOUR INSTRUCTIONAL COURSESELECT ONE: FRI SAT or SUNINCLUDES: CME/CEU credits, available slides for course selected
ACRM.org/preconference
PAID MEMBER ¨ 279 ¨ 349 ¨ 439NON-MEMBER ¨ 349 ¨ 439 ¨ 549
2.5 DAYS INSTRUCTIONAL COURSE PASSINCLUDES: FRI, SAT and SUN INCLUDES: CME/CEU Credits, all available Instructional Course slides
CORE: 26 – 29 SEPT 2021 PRE-CONFERENCE: 24 – 26 SEPT
8-HOUR INSTRUCTIONAL COURSESELECT ONE: FRI SAT or SUNINCLUDES: CME/CEU credits, available slides for course selected
8-HOUR
2.5 DAYS
EARLY BIRD REGULAR ON-SITE
PAID MEMBER 349 399 499
NON-MEMBER 449 499 599
EARLY CAREER DEVELOPMENT COURSE
Early Career Development Course: Virtual registration includes CME/CEU credits. This session connects early career rehabilitation researchers with seasoned professionals who serve as mentors to answer specific questions regarding career development and funding OPPORTUNITIES. This is included in the WORLD PASS.
(This course IS included in WORLD PASS)
ACRM.org/ecdc
EARLY CAREER DEVELOPMENT COURSE
EARLY BIRD REGULAR ON-SITE
PAID MEMBER 349 399 499
NON-MEMBER 449 499 599
LEADERSHIP DEVELOPMENT COURSE
Leadership Development Course: Virtual registration includes CME/CEU credits. This course is designed to help rehabilitation and research professionals begin to develop leadership skills necessary to advance and build the leadership capacity in rehabilitation medicine and research.
(This course IS included in WORLD PASS)
ACRM.org/ldc
LEADERSHIP DEVELOPMENT COURSE
249249319
269
CLICK HERE for the latest deadlines
CLICK HERE for the latest deadlines
CLICK HERE for the latest deadlines
Instructional Courses
TWO-DAY INSTRUCTIONAL COURSE
Al l courses below are INCLUDED in the WORLD PASS. Continuing education credits and conference slides are incl uded. A few content leaders elect not to have their slides available to attendees, therefore some sessions may not be included.
FRI - S AT 24 - 25 SEPT
ICIOA & B Emerging Concepts & Evidence Basis behind Novel Approaches to Managing Chronic Spinal Pain PAIN CP INT NP TEC
FRIDAY 24 SEPT
MORNING 10:00 AM - 2:00 PM 1c2 Concussion: A Vestibular & Ocular Focus for the Treating Clinician (Intermediate Level) CP ATH 81
1cs Hanging by a Thread During Covid-19 Pandemic- Best Practices to Mitigate Frailty for At-Risk Community Dwelling Elderly GER COVID-19 LM
IC6 Responding to Racism, Discrimination, and Microaggressions in Academic Medicine CULTIJRAL COMPETENCT ETHICS
1ca Culinary Coaching Instructional Course LM ATH Bl BHI CAN CP
FULL DAY 10:00 AM - 6:30 PM IC3 A Non Pharmacological Framework for �ent & Treatment to Reduce Pain & Sp.,sticity in Neurological Adult & Pediatric Patients CP Bl GER
IC7 Innovations in Limb Loss and Difference Rehabilitation LR BHS CP
IC9 Integrating Patient Reported Outcomes (PRO) in Rehabilitation Clinical Practice MEAi Bl CP
1c1 I Smartphone Apps for Day-to-Day Management of Executive Function Issues TEC Bl BHI MIL ND PAIN
IC48 ACRM 2021 Integrative Rehabilitation Research Mentoring & Career Development Fellowship for early career researchers CULTURAL COMPETENCY from underrepresented & diverse backgrounds
AFTERNOON 2:30 PM - 6:30 PM ICl2 Post-Traumatic Headaches
ICl4 "Keep Your Move in the Tube": An Evidence-Based Clinical Approached Implementation of a New Paradigm for Management of Cardiac Patients After Sternotomy
1c1s American Spinal Injury Association l/2 day at the ACRM Annual Conference 2021
81 CP
CP
SCI CP PAIN
SATURDAY 25 SEPT
MORNING 10:00 AM - 2:00 PM ET ICl9 FES Cycling & Stepping Interventions to Optimize Outcomes in Persons w/ Neurological Disorders CP ND SCI TEC
IC2 I Rehabilitation Treatm:nt Specification System: Principles & Application in Rehabilitation Education, Research & Clinical Practice CP
IC22 Facilitating Implementation Science in Practice: Secrets of Successful Clinical and Research Partnerships HSR CP
IC23 Longitudinal Data Analysis & Practical Workshop Using R: Part I Introductory Topics MEAi Bl GER HSR ND PED
IC27 Different Paradigms of Electrical Stimulation for Neuromuscular Recovery after Spinal Cord Injury SCI NP
IC36 Management of Vision Deficits Following Acquired Brain Injury Bl CP
FULL DAY 10:00AM - 6:30 PM ICl6 Behavioral Health Group Intervention -An Interactive Workshop BHI CP
ICl7 Introduction to Applying Integrative Cognitive Rehabilitation Psychotherapy to Brain Injury with Co-Occurring Issues 81 BHI CP
1c1a Disorder of Consciousness: The Implementation of Guideline Recommendations for Interdisciplinary Bl CP Clinical Rehabilitation Practice: An Interactive Course
IC25 Uncovering the Obstacles-Using Uniform Terminology to Identify Contextual & Environmental Factors that Affect Participation MEAi CP HSR
IC26 Optimizing Pediatric NeuroRecovery: Benefits of Early Intervention and Activity-Based Therapy PED 81 SCI
IC28 Interdisciplinary Perspectives to Functional Measurement and Assessment of the Stroke Survivor CP
TEC IC29 The User Experience & Usability Research: In-depth look at Interviews, Observational Studies & Usability Testing
AFTERNOON 2:30 PM - 6:30 PM IC24 Longitudinal Data Analysis & Practical Workshop Using R: Part II Advanced Topics 81 GER HIR ND SCI
IC30 Improving Carry-Over: A Practical Lab on Approaches for Translating Therapeutic Gains Into Daily Activities
IC31 Bench to Bedside: A Guide for Implementing Evidence Based Interventions into Practice at Organizational Level
IC32 Home Evaluations for Safe Discharge and Aging-in-Placel
IC33 Rehabilitation for Functional Movement Disorders: The Works
IC34 Restoring Voluntary Grasping Function After Stroke or Spinal Cord Injury Using Functional Electrical Stimulation
SUNDAY 26SEPT
MORNING 10:00 AM - 2:00 PM ET 1c20 A Guide to Best-Practice Interdisciplinary Goal Setting in Clinical Practice
IC35 Rhythm & the Motor System: New Opportunities for Gait Tra ining
IC37 So You Want to be a TBI Expert Witness?
IC38 Interdisciplinary Care for Concussion/Mild Traumatic Brain Injury: A Model for Differential Diagnosis & Management
IC39 Comprehensive Management of Head & Neck Cancer: Optimizing Outcomes Through a Multi-Disciplinary Approach
IC40 Learn how Alexander Technique Interventions Can Complement & Enhance Rehabilitation Research & Interdisciplinary Clinical Practice
IC41 Practice Skills for Rehabilitation Professionals Working With Refugees and Asylum Seekers
IC42 How to Effectively Use Secondary Data in Your Research Program
IC44 NIH Toolbox: Innovative Assessments for the Rehab
IC45 Optimizing Upper Extremity Reconstruction After Spinal Cord Injury: An Interdisciplinary, Systematic & Iterative Approach
IC46 Functional Assessment and Prism Adaptation Treatment for Spatial Neglect after Stroke
IC47 Powering Forward: Wheelchair Setup and Skills for Power Wheelchair Users
CP BHI ND NP
CP Bl SCI
CP GER
CP
TEC CP NP
CP Bl COVID-19
AN CP TEC
81 ETHICS
81 ATH CP
CAN BHS TEC
ATH Bl CP
CP INT
HSR
MEAi BHI
SCI CP TEC
Bl CP
TEC Bl CP GER
TEC
m!II AN: Arts & Neuroscience ATH: Athlete Development & Rehabilitation BHI: Behavioral Health Sciences Bl: Brain Injury Rehabilitation CAN: CANcer rehabilitation CRO i i-CUTTiNG / CC: Spanning Diagnoses IMill II Complementary, lntegra tivo, Rehabilitation Medicine CP: Clinical Practice GER: GERiatric Rehabilitation HSR: Heal th Services Research INT: INT,rnational LR: limb Care LM: lifestyle Medicine MEAS: MEAlurement Mil: Military/veterans affairs ND: Neurodegenerative Disease (e.g. Ml, Parkinson's disease) NP· NeuroPlasticity (includes neuroscience) PAIN: PAI N rehabilitation PED: PEDiatric rehabilitation QUAL: QUAlity Improvement & Implementation Science RT Rehabilitation Research Specifications SCI: Spinal Cord Injury Stroke Rehabilitation TEC: TEChnology (robotics, assistive technology, mHealth)
+1.703.435.5335 ACRM 98th An nual Conference PRE-CON: 24 - 26 SEPT 2021
CORE CON: 26 - 29 SEPT 2021
I N T E R D I S C I P L I N A R YACRM 98th Annual ConferencePROGRESS IN REHABILITATION RESEARCH #ACRM2021
CORE: 26 – 29 SEPT 2021 PRE-CONFERENCE: 24 – 26 SEPT
www.ACRM.org Questions? Looking for help? Please call +1.703.435.5335 or MemberServices@ACRM.orgREG FORM PG 5
www.ACRM.org Questions? Looking for help? Please call +1.703.435.5335 or MemberServices@ACRM.orgREG FORM PG 6
STUDENT / RESIDENT / FELLOW: Attendees enrolled in an accredited school of medicine or approved graduate or undergraduate program or fellowship in a medical rehabilitation discipline.
EARLY CAREER: Professionals during first five years after completion of post-graduate studies.
REHABILITATION PROFESSIONAL: Professionals in medical rehabilitation or a related field who are actively engaged in the practice, administration, education or research of medical rehabilitation.
CONSUMER / NON-PROFESSIONAL CAREGIVER: People with disabilities and caregivers who use rehabilitation services and/or research.
MEMBER: ACRM paid members enjoy savings on ACRM products and events, including annual conference registration. Visit www.ACRM.org/join to become a member and start saving. To receive the Member Rate, one must be an active ACRM Member (not a Special Interest or Networking Group member only) on the day of registration.
NON-MEMBER: A person without a current ACRM membership on the date of registration.
TRANSACTION POLICIES
SUBSTITUTIONS / TRANSFERS BETWEEN REGISTRANTS: Registrants wishing to transfer their registration to another individual must submit a written request/email to memberservices@ACRM.org. Instructional Courses are non-transferable. A substitution fee of $249 USD will be charged against the original registration on transfer requests received before 1 August 2021. No substitutions will be made on or after 1 August 2021. Those who register as non-members retain their 6-month ACRM membership.
CONFERENCE CANCELLATION BY REGISTRANT: ACRM is a non-profit organization. Registrants wishing to cancel their registration and receive a refund for items other than Instructional Courses must submit a written request to memberservices@ACRM.org. Instructional Courses are non-refundable. A cancellation fee of $249 USD will be charged on cancellation requests received on or before 31 May 2021 and the balance remaining will be refunded. On or after 1 June 2021, a cancellation fee of $249 USD or 50% of registration paid, whichever is greater, will be charged and the balance paid will be refunded. If the registration paid is less than or equal to $249, no refund will be given. No refunds will be made on or after 1 August 2021. Those who register as non-members retain their 6-month ACRM membership. Registrants wishing to cancel their course registration (ECDC) and receive a refund for items other than Instructional Courses must submit a written request to memberservices@ACRM.org. Instructional Courses are non-refundable. A cancellation fee of $199 USD or 50% of the course fee, whichever is greater will be charged on cancellation requests received on or before 31 July 2021. No refunds will be made on or after 1 August 2021. Those who register as non-members retain their 6-month ACRM membership.
TYPES OF PAYMENT: Credit card (MasterCard, VISA, American Express, Discover), check/money order (U.S. funds only) made payable to ACRM, wire transfer for an additional $25 fee.
PAYMENT DECLINED: If a credit card payment is declined or a check is returned, the registrant will be notified and an alternative method of payment will be requested. A $15 USD processing fee will be applied for re-billing of a credit card and/or returned checks.
RATE INFO
TERMS & CONDITIONS
I N T E R D I S C I P L I N A R YACRM 98th Annual ConferencePROGRESS IN REHABILITATION RESEARCH #ACRM2021
COURSE CANCELLATION BY REGISTRANT FOR COGNITIVE REHABILITATION TRAINING (CRT), AND/OR EARLY CAREER DEVELOPMENT COURSE (ECD): Registrants wishing to cancel their course registration (CRT, ECD) and receive a refund for items other than ICs must submit a written request to memberservices@ACRM.org. ICs are non-refundable. A cancellation fee of $199 USD or 50% of the course fee, whichever is greater, will be charged on cancellation requests received on or before 31 August 2021. No refunds will be made on or after 1 September 2021. Those who register as non-members retain their 6-month ACRM membership.
CORE: 26 – 29 SEPT 2021 PRE-CONFERENCE: 24 – 26 SEPT
www.ACRM.org Questions? Looking for help? Please call +1.703.435.5335 or MemberServices@ACRM.orgREG FORM PG 7
TERMS AND CONDITIONS
FORCE MAJEURE: In the event of a full or partial cancellation of the ACRM Annual Conference due to a natural disaster or other force beyond the control of ACRM, ACRM will refund registrations in proportion with the cancellation insurance proceeds it receives.
RECORDING BY ATTENDEES: Recording or photographing conference sessions by an attendee, panel discussions or sponsor exhibits is strictly prohibited.
ETIQUETTE: To make the conference experience an enjoyable event for all attendees, we ask that you keep the following in mind: Ensure that all comments within the online virtual networking are professional and respectful of all attendees and presenters.
SOLICITATION: By registering, you agree not to solicit vendors or exhibitors
STATEMENT OF LIABILITY WAIVER — TERMS OF REGISTRATION: ACRM or any other conference sponsor claims no liability for the acts of any suppliers at or to the meeting, or for the safety of any registrant while in transit to or from this event. ACRM shall not be liable for any delays or failure in performance or interruption of services resulting directly or indirectly from any cause or circumstance beyond the reasonable control of the organization including but not limited to, acts of God, pandemic, acts of public enemy, war, accidents, fires, electrical failures, strikes, labor disputes, postal delays, explosions, governmental order or regulations.
ACRM reserves the right to cancel the conference or any function without liability. Registrants who purchased non-refundable airline tickets do so at their own risk. The total amount of any liability of ACRM will be limited to a refund of the registration fee.
By attending the conference, the registrant agrees to indemnify and hold harmless ACRM, other conference sponsors, their respective officers, directors, and agents, against all claims arising out of actions or omissions of the supplier, attendee, or other individual at or in connection with the conference except for ACRM’s or any other sponsor’s own gross negligence or willful misconduct.
ACRM or any other conference sponsor reserves the right to substitute an equally qualified speaker in case of an emergency or cancellation.
ACRM or any conference sponsor has no duty of due diligence with respect to presenters, exhibitors, or sponsors, and makes no endorsements of any presentation or product.
Sessions, events, and exhibits can only be attended by registered attendees.
PLEASE CHECK! I have read and agree to the Terms & Conditions above and on previous page
I N T E R D I S C I P L I N A R YACRM 98th Annual ConferencePROGRESS IN REHABILITATION RESEARCH #ACRM2021
CORE: 26 – 29 SEPT 2021 PRE-CONFERENCE: 24 – 26 SEPT
COMMUNICATION: ACRM will assign registrants to the community groups according to the sessions that they sign up for. No action will be taken for registrants that are already part of the community group.
www.ACRM.org Questions? Looking for help? Please call +1.703.435.5335 or MemberServices@ACRM.orgREG FORM PG 8
Type of Payment Enclosed
Check/Money Order (US Funds Only) Check #__________Make check payable to: ACRM
Credit Card (fill out information below)MasterCard Visa ❏ American Express ❏Discover
Credit Card #:__________________________________________________
Expiration Date:__________________ Security Code:_______________
Print name as it appears on card:_____________________________________
Cardholder’s Signature: ___________________________________________
Cardholder’s e-mail address: _____________________________________
Check here if you want to bundle ACRMmembership/pay your dues renewal too.
2904
21
$___________TOTAL AMOUNT in USD < The sum from your selections on the previous pages.
EMAIL: MemberServices@ACRM.org ORFAX: +1.866.692.1619 ORMAIL CHECKS TO: PROCESS CREDIT CARD FORMS TO: ACRM: PO Box 896700 email MemberServices@ACRM.org
Charlotte, NC 28289-6700
PAYMENT
BILLING ADDRESS Check if same as mailing address on pg 1
SUBMIT
Address 1
Address 2
City
State / Province
Zip / Postal Code
Country
(to send confirmation)
www.ACRM.org
For questions related to the status of registrations, please contact MemberServices@ACRM.org or phone: +1.703.435.5335
Online registration at:
?s
DISCOUNT CODE:____________________________________________
I F A P P L I C A B L E
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I N T E R D I S C I P L I N A R YACRM 98th Annual ConferencePROGRESS IN REHABILITATION RESEARCH #ACRM2021
CORE: 26 – 29 SEPT 2021 PRE-CONFERENCE: 24 – 26 SEPT
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