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2019 AKAPTA Spring Conference
Registration
May 4, 2019
Registrant Information
First Name *
Last Name *
Address *
City *
State *
Select a State/Province
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AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
---------------
AF - Armed Forces Africa
AA - Armed Forces Americas (except Canada)
AC - Armed Forces Canada
AE - Armed Forces Europe
AM - Armed Forces Middle East
AP - Armed Forces Pacific
---------------
AB - Alberta
BC - British Columbia
MB - Manitoba
NB - New Brunswick
NF - Newfoundland
NT - Northwest Territories
NS - Nova Scotia
NU - Nunavut
ON - Ontario
PE - Prince Edward Island
QC - Quebec
SK - Saskatchewan
YT - Yukon
---------------
AS - American Samoa
FM - Federated States of Micronesia
GU - Guam
MH - Marshall Islands
MP - Northern Mariana Islands
PW - Palau
PR - Puerto Rico
VI - Virgin Islands
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XX - Other State/Province/Territory
Zipcode *
Phone *
Email *
Designation *
PT
PTA
Student
Other
Registration Options
Member Type
Early-Bird Registration
(On or before April 14, 2019)
Advanced Registration
(April 15-21, 2019)
On-Site Registration
(May 4, 2019)
APTA
PT
Member
$175
$250
$300
APTA
PTA
Member
$125
$200
$250
APTA or AKOTA
Student
Member
$50
$50
$75
AKOTA
OT
Member
$175
$250
$300
AKOTA
COTA
Member
$125
$200
$250
Non
-Member
$300
$350
$400
Total
$
Payment Information
Name on Card *
Billing Postal Code *
Billing Street Address *
Enter:
Refund/Cancellation Policy
Registration less $50 if cancellation request is received by April 21, 2019.
Mail cancellation request to:
Alaska Physical Therapy Association,
140B Purcellville Gateway Drive, Suite 120,
Purcellville, VA 20132
Questions? Call 907-202-8776, or e-mail
info@akapta.org
Cancel Application
Submit Registration