Registration Form
2nd Annual Pacific Northwest Regional Brain Injury Conference 2004
Portland, Oregon October 1 & 2, 2004

* indicates required field

First Name* Last Name*
Badge name
Address City State Zip
Phone* Fax Email*
Special Needs

Please check all that apply:

I am interested in volunteering at the conference. Please call me.
I am requesting continuing education credits (CEU's and CME's) at the conference.
I would like to make a donation to cover costs of survivors unable to pay (see below).
Call me about sponsorship/exhibitor opportunities.

 Conference Registration Fees:
Registration fees include continental breakfast and lunch on Fridayand Saturday; all conference related materials, continuing medical/educational units; and access to all conference sessions, exhibits, posters and roundtables.
BIAOR Member***
* Courtesy: Courtesy rate is for brain injury survivors with limited means.
**Family: Family refers to up to three members of a family, each person pays listed price.
Accompanying Person
Accompanying Person: Registration fee includes continental breakfast, dinner on Friday; lunches and exhibition only. Fee does not include admission to conference sessions.
American Academy for the Certification of Brain Injury Specialist Training and Examination

All forms must be submitted by September 15: Certification Training for Brain Injury Specialists Information
 Membership Fee
 (Become a BIAOR member now and receive the discounted registration Fee)
 Scholarship Contribution  
 (donation to assist in covering the cost of survivors with limited funds)
 Registration and Membership  Total
(Please add totals from Registration Fee, Membership Fee and Scholarship Contribution for final total costs)
 * Courtesy rate is for brain injury survivors with limited means.
 *** A limited number of conference scholarships are available to survivor members of BIAOR to cover the costs of conference registration. For more information, contact the BIAOR office: 503-413-7707

Payment in full must accompany your registration. Payment may be made by check or money order (use pdf registration form), VISA or MasterCard.
 Amount to be charged $     VISA  MasterCard   Check in the Mail
 Name on Credit Card    Account # Expiration Date 

Confirmation and Cancellation Policies

Confirmation letters will be e-mailed within 5 business days of receipt of registration. If your confirmation is not received within 2 weeks, please contact us via e-mail at or by telephone at +1-800-544-5243 or 503-413-7707, M-F, 9-5.

Cancellations must be received in writing by September 26, 2004 to qualify for a refund. A $25.00 administrative fee will be deducted. Substitutions are always welcomed and no-shows will be billed.


Registration, Payment, and Refund Policy

Please submit payment with completed registration form.
Fees are payable by check, credit card, or state government purchase orders which obligate payment.
All payments must be received by September 15, 2004, to be eligible for discount.
All cancellations are subject to a $25 processing fee.
No refunds will be issued for cancellations received after September 26; however, registrations are transferable.

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