Eastern Clinical Training Seminar

Form Instructions:

Please answer every field before hitting “Submit.”

Once you submit this form, it will redirect you to a payment prompt, which is required for you to complete registration.

This is a working conference; every attendee brings a case.

Thank you!

Your Name

First Name

Last Name

Phone

Country

(###)

###

####

CPSP Member

Chapter Affiliation Member

Certified Clinican

Diplomate

Student

Training Center

Training Supervisor's Name

First Name

Last Name

CPE Unit

Have you attended this seminar before?

Meal Preference