SEAK, Inc. Hyannis July 2004 
REGISTRATION FORM

To register, call SEAK, Inc. at 508-457-1111, or Print this form and complete the requested information (neatly, please), and FAX to SEAK, Inc. at 508-540-8304, with credit card information. Or mail with credit card information or check to:  SEAK, Inc. PO Box 729, Falmouth, MA 02540                                                                                                                                                           priority code: net

Please register me for:
___Twenty-fourth Annual Workers’ Compensation and Occupational Medicine  
       Seminar ($695:July 20-22, 2004)

___Designing Effective Return To Work Programs  ($295:July 19, 2004)
___ADA, FMLA, and Workers' Compensation:  In Depth ($295:July 19, 2004)
___Workers' Compensation Legal Issues and Defense Strategies ($295:July 19, 2004)
___Diagnosing and Treating Chronic Pain:  The Multidisciplinary Approach ($295:July 19, 2004)
___Minimizing Workplace Stress and Facilitating Work Restoration ($295:July 19, 2004)
___IME Report Writing Workshop ($295:July 19, 2004)

I would like to apply for the following credits (Please check as many as are applicable):

__Attorney      __Case Manager        __Disability Specialist            __MD/DO
         __ Occupational Health Nurse             __ Rehabilitation Counselor            __Nurses

  Check Enclosed (made out to SEAK, Inc.)
  Credit Card Billing Type of card: ___Visa ___MC ___AE
Card No.

Exp.Date:
Signature

Please print or type all information. Use abbreviations as necessary.

Name                                                                                                                                                              Title
Name of Organization
Address
City                                                                           State                        Zip
Phone (Area Code/Number)                                             Fax
E-Mail
Specialty

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SEAK, Inc. FAX  (508) 540-8304