PT 40th Anniversary

40th Anniversary of Physical Therapy
at The University of Scranton
Saturday, September 28

*First Name

*Last Name

*Address Line1

Address Line2

*City

*State / Province

*Zip / Postal Code

*Country

*Email

Class Year

Phone

*Will you be attending the 40th Anniversary of Physical Therapy Celebration?

Yes

*Number of guests you are registering (including yourself):

1st Attendee

*First Name

*Last Name

Class Year

*Will you be attending the Friday evening get together at Backyard Ale House?

Yes
No

*Will you be attending the CEU session?

Yes
No

*Continuing Education Fee For Attendee (proceeds from this fee will support service trips for our students)

X $10.00

*Will you be attending the Dinner?

Yes, I will be attending dinner
No, I am unable to attend dinner

*Dinner Registration Fee For Attendee

X $40.00

Please indicate any special dietary needs:

2nd Attendee

*First Name

*Last Name

Class Year

*Will you be attending the Friday evening get together at Backyard Ale House?

Yes
No

*Will you be attending the CEU session?

Yes
No

*Continuing Education Fee For Attendee (proceeds from this fee will support service trips for our students)

X $10.00

*Will you be attending the Dinner?

Yes, I will be attending dinner
No, I am unable to attend dinner

*Dinner Registration Fee For Attendee

X $40.00

Please indicate any special dietary needs:

3rd Attendee

*First Name

*Last Name

Class Year

*Will you be attending the Friday evening get together at Backyard Ale House?

Yes
No

*Will you be attending the CEU session?

Yes
No

*Continuing Education Fee For Attendee (proceeds from this fee will support service trips for our students)

X $10.00

*Will you be attending the Dinner?

Yes, I will be attending dinner
No, I am unable to attend dinner

*Dinner Registration Fee For Attendee

X $40.00

Please indicate any special dietary needs:

4th Attendee

*First Name

*Last Name

Class Year

*Will you be attending the Friday evening get together at Backyard Ale House?

Yes
No

*Will you be attending the CEU session?

Yes
No

*Continuing Education Fee For Attendee (proceeds from this fee will support service trips for our students)

X $10.00

*Will you be attending the Dinner?

Yes, I will be attending dinner
No, I am unable to attend dinner

*Dinner Registration Fee For Attendee

X $40.00

Please indicate any special dietary needs:

5th Attendee

*First Name

*Last Name

Class Year

*Will you be attending the Friday evening get together at Backyard Ale House?

Yes
No

*Will you be attending the CEU session?

Yes
No

*Continuing Education Fee For Attendee (proceeds from this fee will support service trips for our students)

X $10.00

*Will you be attending the Dinner?

Yes, I will be attending dinner
No, I am unable to attend dinner

*Dinner Registration Fee For Attendee

X $40.00

Please indicate any special dietary needs:

6th Attendee

*First Name

*Last Name

Class Year

*Will you be attending the Friday evening get together at Backyard Ale House?

Yes
No

*Will you be attending the CEU session?

Yes
No

*Continuing Education Fee For Attendee (proceeds from this fee will support service trips for our students)

X $10.00

*Will you be attending the Dinner?

Yes, I will be attending dinner
No, I am unable to attend dinner

*Dinner Registration Fee For Attendee

X $40.00

Please indicate any special dietary needs:

7th Attendee

*First Name

*Last Name

Class Year

*Will you be attending the Friday evening get together at Backyard Ale House?

Yes
No

*Will you be attending the CEU session?

Yes
No

*Continuing Education Fee For Attendee (proceeds from this fee will support service trips for our students)

X $10.00

*Will you be attending the Dinner?

Yes, I will be attending dinner
No, I am unable to attend dinner

*Dinner Registration Fee For Attendee

X $40.00

Please indicate any special dietary needs:

8th Attendee

*First Name

*Last Name

Class Year

*Will you be attending the Friday evening get together at Backyard Ale House?

Yes
No

*Will you be attending the CEU session?

Yes
No

*Continuing Education Fee For Attendee (proceeds from this fee will support service trips for our students)

X $10.00

*Will you be attending the Dinner?

Yes, I will be attending dinner
No, I am unable to attend dinner

*Dinner Registration Fee For Attendee

X $40.00

Please indicate any special dietary needs:

9th Attendee

*First Name

*Last Name

Class Year

*Will you be attending the Friday evening get together at Backyard Ale House?

Yes
No

*Will you be attending the CEU session?

Yes
No

*Continuing Education Fee For Attendee (proceeds from this fee will support service trips for our students)

X $10.00

*Will you be attending the Dinner?

Yes, I will be attending dinner
No, I am unable to attend dinner

*Dinner Registration Fee For Attendee

X $40.00

Please indicate any special dietary needs:

10th Attendee

*First Name

*Last Name

Class Year

*Will you be attending the Friday evening get together at Backyard Ale House?

Yes
No

*Will you be attending the CEU session?

Yes
No

*Continuing Education Fee For Attendee (proceeds from this fee will support service trips for our students)

X $10.00

*Will you be attending the Dinner?

Yes, I will be attending dinner
No, I am unable to attend dinner

*Dinner Registration Fee For Attendee

X $40.00

Please indicate any special dietary needs:

Your generous support of our Physical Therapy program can make a significant impact for our current and future students – consider making a gift to help continue our mission.

*Would you like to make an addition gift to support PT students?

Yes
Not at this time

Gift Amount: