visABILITIES Rehab Services Order Form

visABILITIES Secure Registration Form

(Red indicates this entry is required)

Employer/School		OT PT SLP Student
First Name:		Last Name:	Int:
Mail To Address:
Mail To City:		Mail To State:
Mail To Zip:		Mail To Country:
Employer Address:
Employer City:		Employer State:
Employer Zip:		Employer Country:
Home Phone:		Work Phone:	Ext.
E-mail:	Please send me e-mail about special offers and promotions.

Courses Registration Deposit Only






	Apply $50 Voucher From Previous Course (Not Valid For Deposit)
	Three or More Paying Registrants are Attending from My Institution
Total Amount Due*
		recalculate

If registering on-line, enter credit card information:

Card Type:	Mastercard Visa
	Personal Credit Card Employer Credit Card
Credit Card Number:	Expires: /
	Please enter the anti-fraud code: This is a three digit code on the back of your card as shown in the picture on the left. *** For Amex it is a four digit code on the front of your card.

or, Print Completed Form and Mail with Payment to:

visABILITIES Rehab Services Inc
4000 W 6th St #295
Lawrence, KS 66049

By Fax:
(785) 856-4987

*Discounts Subject to Validation

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