REGISTRATION FORM
12th Annual Clinical Eye Care Conference
6th Annual Alumni Reunion
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NAME
____________________________________
ADDRESS
____________________________________
CITY
____________________________________
STATE
____________________________________
ZIP
____________________________________
TELEPHONE
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E-MAIL (Required)
____________________________________
FLORIDA LICENSE NO. (required)
____________________________________
OE TRACKER NO. (Required)
Lookup
your OE Tracker Number
To learn more about the OE Tracker program, please click on the following
link: OE Tracker
PLEASE NOTE: Alumni must be current chapter members to receive discounted registration fees.
If you haven't paid your dues for 2008, please do so as part of this registration.*
Please check off your registration status:
Early Registration - Postmarked by April 16, 2008 |
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0
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Friday Morning - Optometric Practice Enhancement Program - $80 (*Alumni Chapter Members Free) |
| 0 | Friday Afternoon - Florida Board Required Courses - $80 (*Alumni Chapter Members $40) |
| 0 | Saturday or Sunday Single Day Registration - $140 (*Alumni Chapter Members $70) |
| 0 | Saturday and Sunday Registration - $280 (*Alumni Chapter Members $140) |
| 0 | Complete Conference Registration (Includes All Courses - Friday, Saturday, & Sunday) - $390 (*Alumni Chapter Members $195) |
| 0 | Class of 1998 - 10 Year Graduation Anniversary - Free |
Regular Registration - Postmarked After April 16, 2008
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0
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Friday Morning - Optometric Practice Enhancement Program - $100 (*Alumni Chapter Members Free) |
| 0 | Friday Afternoon - Florida Board Required Courses - $100 (*Alumni Chapter Members $50) |
| 0 | Saturday or Sunday Single Day Registration - $180 (*Alumni Chapter Members $90) |
| 0 | Saturday and Sunday Registration - $360 (*Alumni Chapter Members $180) |
| 0 | Complete Conference Registration (Includes All Courses - Friday, Saturday, & Sunday) - $500 (*Alumni Chapter Members $250) |
| 0 | Class of 1998 - 10 Year Graduation Anniversary - Free |
Onsite Registration |
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| 0 | Friday Morning - Optometric Practice Enhancement Program - $120 (*Alumni Chapter Members Free) |
| 0 | Friday Afternoon - Florida Board Required Courses - $120 (*Alumni Chapter Members $60) |
| 0 | Saturday or Sunday Single Day Registration - $210 (*Alumni Chapter Members $105) |
| 0 | Saturday and Sunday Registration - $420 (*Alumni Chapter Members $210) |
| 0 | Complete Conference Registration (Includes All Courses - Friday, Saturday, & Sunday) - $580 (*Alumni Chapter Members $290) |
| 0 | Class of 1998 - 10 Year Graduation Anniversary - Free |
Alumni Banquet - Honoring the Class of 1998
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| 0 | Class of 1998 - No Charge for Alumni and One Guest |
| 0 | Alumni, Faculty, Administration, and Their Guests - $50 per person |
| 0 | Optometric Students - $25 per person |
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Nova Southeastern University Alumni Association - College of Optometry Chapter |
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| 0 | *2008 Membership Dues - $25 |
Special Needs
| 0 | Kosher Meals Requested |
| 0 | Hearing Assistive Device Requested |
| 0 | Wheelchair Access Requested |
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I Will Attend the Following Meal Functions
(please check all that apply)
| 0 | Friday Breakfast (OPEP Attendees Only) |
| 0 | Friday Lunch (OPEP Attendees Only) |
| 0 | Saturday Breakfast |
| 0 | Saturday Lunch |
| 0 | Alumni Reception and Dinner (Saturday) |
| 0 | Sunday Breakfast |
| 0 | Sunday Lunch |
______________________________________________________
0 I am an alumnus
of the NSU College of Optometry
Class of _________
______________________________________________________
Please complete this registration form, attach a check payable to
NSU College of Optometry, and mail both to:
Lorena Lizausaba
Coordinator
Office of Continuing Education & Alumni Affairs
College of Optometry
Nova Southeastern University
3200 South University Drive
Ft. Lauderdale, FL 33328