Member Convention Registration

Please read and fill out the Registration form below.

No registration will be accepted without payment.

If you are planning to check out as a guest using PayPal, you must either use Firefox or Brave browsers. PayPal has blocked other browsers from allowing guests to check out without making an account.

Last Name *

First Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Phone Number *

Email Address *

Chiropractic License Number *

Name & Address As It Appears on Your Chiropractic License *

Lunch and Dinner Ticket Information

PLEASE NOTE: You already receive one free lunch and one free dinner ticket with your registration. The tickets you can choose on this form are extras for spouses, employees or students.

Do you want extra Lunch Tickets?Select Your Ticket Number ($40 each)

Do you want extra Dinner Tickets?Select Your Ticket Number ($50 each)

Do you want to purchase a ticket for your staff/spouse/student at $30? (This includes lunch, does not include dinner.)

Your registration includes one state CE (Continuing Education) certificate. Please indicate how many additional state CE certificates you wish to purchase at $50 each.

What Other State Are You Licensed In?

What Is Your License Number?

Registration Fee *$349

Registration Fee TotalIncludes your registration fee and all selected extra tickets

Cancellation Policy *Please acknowledge that if you cancel more than one week before the event, there is a $50 administrative fee. There is no refund if you cancel 7 days prior to the event.By checking the box above, you acknowledge that you have read and will abide by our cancellation policy.

Choose Your Payment Method *PayPalStripe

Credit Card Payment Option

PLEASE NOTE: You do not need a Paypal account to pay your registration fee. When you click the Paypal button, you may enter a separate Credit or Debit Card as your payment option by clicking the button titled "Pay with Debit or Credit Card."

Credit Card Payment Option

PLEASE NOTE: You do not need a Stripe account to pay your registration fee. You can simply enter your credit or debit card information into the Stripe payment field.

Credit / Debit Card *

** Cancellation Policy: Full refund minus $50 administrative fee if requested 7 days prior to event. No refunds after that time.