2019 Fall Registration Form

Personal Information

Name*

First Last

AARC Number

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Is this your home address?*

Yes
No

Phone

Email*

Enter Email Confirm Email

Permission to Advocate on Your Behalf*

I give the PACT committee of the CTSRC permission to use the following information whenever there is legislation that might impact the profession of Respiratory Therapy or our patients. The permission is granted from now - Dec 31, 2019. I understand that this list will not be shared or sold.

Yes
No

Employment Information

Facility or School*

Job Function*

if other, If other, identify your employment status or position.

Would you like a vegetarian meal?

Yes
No

Do you require dietary accommodations?

Yes
No

Special Dietary Accommodations

AARC Member Early Registration

Price: $40.00 Quantity:

Non AARC Member Early Registration

Price: $128.00 Quantity:

Non AARC fees include a digital membership to the AARC.

AARC Student Member Early Registration

Price: $20.00 Quantity:

Coupon

If you have a coupon code, enter it in the box.

Total

$0.00

Refund Policy*

It is policy of the CTSRC that all cancellations must be submitted in writing, 14 calendar days before the scheduled event to be eligible for a registration fee refund. Refund requests must be made in writing via the "Contact Us" form found under the "About Us" Tab. A $25 administrative fee will be deducted from the refund.

I have read the refund policy.

Payment Choice

When you click REGISTER NOW, you will be directed to the PayPal site to complete your transaction. Payment can be made using a credit card OR Pay Pal account.

Checks must be mailed to:

CTSRC Treasurer

90 Creamery Rd

Durham, CT 06422

Checks must be received 2 weeks before the event (Sept 11) to be valid.