Registration Form

Please print the form, complete, and fax to 618-395-8111. The basic office registration is $159 and includes one person (DC or staff member) enrollment in the seminar. Please add the additional fees accordingly. Office staff may attend the seminars without the DC. Confirmation of payment and reservation will be faxed to your office the day before the seminar date. TO USE PAYPAL CLICK HERE.
Seminar date:
 
Location:
 
Doctor attending (names):
 
Staff attending (names):
 
Prices:
$159.00 for the first D.C. or C.A. in office.
$40.00 for additional D.C. in the same office.
$15.00 for additional C.A. in the same office.
(On-site registration add $20 to above fees.)
Your total:
 
Doctor's Name:
 
Office Name:
 
Billing address:
 
City, State, Zip:
 
Phone:
 
Fax:
 
Email:
 
Payment type**
Credit card number
3-digit pin**
Exp. date
       
**Payment type accepted "Visa" or "Mastercard", 3-digit pin located on the back of the card.
You may also send the completed form with a check payable to "Dr. Gary R. Street" to the address on the top of this form.
Confirmation of payment and reservation will be faxed to your office the day before the seminar date.