Registration Form for Reflex Course Part 1 Name* First Last This is how your name will appear on your certificate of completion.Profession*Occupational TherapistPhysical TherapistSpeech TherapistPsychologistEducatorOtherHow many years are you working?*If you are a speech therapist and would like your participation in this course to go to your ASHA CE Registry, please provide your ASHA number. Company Name Address* Street Address City State / Province / Region ZIP / Postal Code Work PhoneHome/Cell Phone*Email* Course confirmation will be sent to this email.How did you find out about the course?* Email announcement Facebook Instagram Hands on OT website Employer Other Comments or special requestsProduct Name* One Day Registration (after July 22, 2019) - $265 Both Days Standard Registration (after July 22, 2019) - $515 Note: Monday, September 16th is open to all interested participants. Tuesday, September 17th is open to licensed OTs, COTAs, PTs, PTAs and SLPs only. If payment for both days is received and you are not one of the licensed professionals listed above, a $20 processing fee will be deducted from your tuition when the difference is refunded. If you have any questions, please email us at email@example.com or call us at (212) 884-9101 before processing payment. Thank you!License Number* OT, COTA, PT, PTA or SLP license required if attending both days of the courseTotal $0.00 When you click "Register" below, you will be transferred to PayPal to complete the payment process.