Dry Needling (DN) Registration To register for any of our programs, please complete the enclosed registration form (next page) and mail of fax the form to us. Fees Cost of the DN 1-3 courses is US $895 each. Cost of the DN-4 course is $995, which includes the fees for the examinations. Discounts Register for 2 courses at a time and receive a 5% discount plus a one-year free membership of the International Myopain Society. Medical and physical therapy residents are eligible for a 10% discount. Proof of resident status is required. Recent graduates of entry-level professional degree programs receive a 10% discount on the DN 1-03 courses during the first two years after graduation. Proof of graduation and the graduation date are required. Participants who retake a course receive a 50% discount. There is no discount for the DN-4 course. Combinations of discounts are not permitted. Dress Casual and comfortable. Men are requested to bring shorts or bathing suits; women, shorts and halter tops, to wear for the practicum sessions. Attendees will practice on each other during the practicum sessions and must be prepared to expose the body region of study to enhance the overall learning experience. Identification and treatment of myofascial trigger points requires short fingernails. Cancellation Policy More than 2 weeks prior to a course: 80% refund. Within 2 weeks of a course, no refunds. We reserve the right to cancel any workshop at any time. If unforeseen circumstances occur and the course is canceled, the full registration fee will be returned or applied to a future course (if so desired), but we will not be responsible for any charges incurred by the registrant, including hotel and airline fees. Questions? Contact our offices at 240.396.6946 or 855.209.1832 or email us at info@myopainseminars.com. Myopain Seminars 4405 East West Highway, Suite 404 Bethesda, MD 20814-4535 Phone: 240.396.6946 / 855.209.1832 Fax: 301.656.0664 Email: info@myopainseminars.com 1
Registration General Information, Selections & Payment General Information Name and title(s) _ (as you would like it to appear on your course certificate) Profession/Specialty I am licensed in (state) Lic Number Street Address City State Zip/Postal Code Country Work Phone Home Phone Fax E-mail address! I have special needs. I will contact Myopain Seminars to discuss these. Select the courses of your choice on the next pages. 2
WORKSHOP SELECTIONS Date of Workshop Cost q DN-3 AZ Advanced I Jan 10-12, 2014 $895 courses: Jan 10-12, 2014 $895 courses: q DN-2 TX Foundations II Jan 24-26, 2014 $895 q DN-3 NC Advanced I Feb 7-9, 2014 $895 courses: q DN-1 TX Foundations I Feb 21-23, 2014 $895 q DN-2 MN Foundations II Feb 28-Mar 2, 2014 $895 q DN-3 TN Advanced I Feb 28-Mar 2, 2014 $895 courses: q DN-1 MD Foundations I Mar 7-9, 2014 $895 q DN-1 WY Foundations I Mar 7-9, 2014 $895 q DN-4 AZ Advanced II Mar 21-23, 2014 $995 Date of Completion of DN-3 course: Mar 21-23, 2014 $995 Date of Completion of DN-3 course: q DN-2 VA Foundations II Mar 28-30, 2014 $895 q DN-2 CT Foundations II Apr 4-6, 2014 $895 q DN-3 TX Advanced I Apr 11-13, 2014 $895 courses: q DN-4 TN Advanced II Apr 25-27, 2014 $995 Date of Completion of DN-3 course: q DN-2 MD Foundations II May 2-4, 2014 $895 q DN-3 VA Advanced I courses: May 16-18, 2014 $895 3
q DN-4 NC Advanced II May 16-18, 2014 $995 Date of Completion of DN-3 course: q DN-2 WY Foundations II May 30-Jun 1, 2014 $895 q DN-1 MD Foundations I Jun 6-8, 2014 $895 Jun 27-29, 2014 $895 courses: q DN-4 VA Advanced II Jul 11-13, 2014 $995 Date of Completion of DN-3 course: q DN-2 MD Foundations II Aug 15-17, 2014 $895 Sep 5-7, 2014 $995 Date of Completion of DN-3 course: q DN-3 CT Advanced I Sep 5-7, 2014 $895 courses: q DN-3 WY Advanced I Sep 12-14, 2014 $895 courses: q DN-4 TX Advanced II Sep 12-14, 2014 $995 Date of Completion of DN-3 course: q DN-1 MD Foundations I Oct 17-19, 2014 $895 courses: q DN-4 WY Advanced II Date of Completion of DN-3 course: q DN-4 CT Advanced II Date of Completion of DN-3 course: Date of Completion of DN-3 course: Nov 7-9, 2014 $895 Nov 14-16, 2014 $995 Dec 5-7, 2014 $995 Jan 9-11, 2015 $995 SUB-TOTAL: 4
SELECT A DISCOUNT SUB-TOTAL: *2 workshops (5%) + IMS Membership Medical or physical therapy residents (10%) Recent graduate (within 2 years of graduation: 10%) Previous participant (50%) CODE: ** Only one discount applies; Combinations of discounts are not allowed. *** No discounts on DN-4 Discount: Textbook q Trigger Point Dry Needling (Dommerholt/Fernández-de-las-Peňas) required for all dry needling courses $82 q Myofascial Trigger Points: Pathophysiology and Evidence-Informed Diagnosis and Management (Dommerholt/Huijbregts) (not required) $54 Total Payment Method of Payment q Check (from an American Bank), payable to Myopain Seminars. Please note, your registration will only be confirmed when we receive your check in the mail. Send it to Myopain Seminars, 4405 East West Highway, Suite 404, Bethesda, MD 20814-4535 q Credit Card: q Visa q MasterCard q Discover q American Express Name (as it appears on the card): Credit Card Number: Expiration Date: _ Signature: _ 5