First Adjustment Registration Registration Form FIRST ADJUSTMENT REGISTRATION Select an Event:* I want to attend the October 16-17 event in Denver, Colorado I want to attend the October 30-31 event in Dallas, Texas D.C. Student Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Office Phone*Cell Phone*Credit Card InformationWe accept VISA, MasterCard, American Express and DiscoverCredit Card #* Security Code* Expiration Date* Check if Credit Card Billing Address is same as above Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Registration Fees: For Doctor Saturday ONLY: $299 ADD: Sunday Technique (LIMITED AVAILABILITY): $119 License State:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLicense Number: * There is a $50 processing fee for continuing education credits. Please note that providing us with your license number does not guarantee continuing education credit for the event. For a list of CE approved states or provinces please visit our FAQ page or call our office at (559) 291-7800 with any questions.Add another State and License number Yes Check this box if you do NOT need/want continuing education credit, otherwise, leave this box unchecked. Warning, by checking this box you are indicating that you do not need continuing education credit for this event and will not be charged the $50 processing fee.There is a $50 processing fee for each state submitted for continuing education. License State:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLicense Number: Add another State and License number Yes There is a $50 processing fee for each state submitted for continuing education. License State:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLicense Number: Add another State and License number Yes There is a $50 processing fee for each state submitted for continuing education. License State:AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLicense Number: Chiropractic AssistantsLimited to two per Doctor: $99 for a Single Assistant OR $179 for Two Assistants Registration Fees: For Student Saturday ONLY: $185 ADD: Sunday Technique: $99 (Students will be put on a Waiting List due to limited availability – you will not be charged for Sunday until you are approved for attendance) Family Wellness Practice Consultation Yes, I am interested in a complimentary 20-minute consultation. Dr. Claudia Anrig has been an international speaker and educator as well as a successful Family Wellness Practitioner for over 35 years. With this experience, she has offered her wisdom to hundreds of doctors over the past 16 years in her Generations program. As an attendee of First Adjustment, she would like to offer you a complimentary 20-minute consultation to discuss your dream Family Practice. If you are interested in taking advantage of this opportunity, please indicate by checking the box above and you will be contacted by one of our Generations support staff members.Cancellation Policy Cancellations received in our office up to 14 days prior to the seminar date are subject to a 20% service charge. Cancellations after the 14-day deadline, and up to 5:00 PM on the day prior are subject to a 40% service charge. “No shows” or cancellations the day of the seminar are liable for the entire fee. Any cancellation fees charged can be applied as a credit toward registration fees for a future event. All cancellations must be in writing or via email. If First Adjustment cancels for any reason, our liability is limited to the return of the registration fee only. First Adjustment will not reimburse any registrant for any travel or hotel cancellation fees or penalties.* I accept the cancellation policy. * Seminar Policies We carefully adhere to CE requirements and, as such, signing in and out of each session on time will be necessary for full CE credit. Regarding children in attendance, although the seminar revolves around this very special segment of the population, to preserve the quality of this program, we request that children remain outside the event room during the entire presentation. No video or audio recording of Dr. Anrig is allowed, however, photographing attendees during the technique session on Sunday is allowed and encouraged for review. * I accept the seminar policies. * Liability Policy By registering for this event, I acknowledge the contagious nature of COVID-19 and other illnesses and further acknowledge that First Adjustment and its administration, the hotel, vendors and instructor cannot guarantee that I will not contract an illness during this event and I affirm that I understand the risks.* I accept the liability policy. * Social-Distancing Policy By registering for this event, I acknowledge that this seminar includes lectures combined with a hands-on experience. It is possible that the instructor and/or other attendees may not be able to maintain a social-distance. While attendees are not required to participate in the hands-on portion to receive CE credits; it should be noted that the seminar and instructor will not be responsible for maintaining social-distancing.* I accept the social-distancing policy. * Hotel Information Our Denver event is being held at the Hyatt Place Denver Pena Station located at 6110 N Panasonic Way in Denver, Colorado. They are offering a special rate for accommodations at this same hotel of just $154 per night plus applicable fees and taxes. Call (888) 591-1234 to reserve your rooms and be sure to mention the First Adjustment Seminar. Room reservations must be made by September 23rd to receive the discounted rate. There is free self-parking and a free shuttle to and from the airport (airport code DEN). Our Dallas event is being held at the Dallas/Fort Worth Airport Marriott located at 8440 Freeport Parkway in Irving, Texas. They are offering a special rate for accommodations at this same hotel of just $109 per night plus applicable fees and taxes. Call (888) 236-2427 to reserve your rooms and be sure to mention the First Adjustment Seminar. Room reservations must be made by October 15th to receive the discounted rate. There is free self-parking and a free shuttle to and from the airport (airport code DFW).How did you hear about our First Adjustment Seminar? (Check as many as apply)* Facebook Postcard College Generations Member Include any comments here pleaseTo register for the First Adjustment event by phone or if you have any questions call (559) 291-7800.NameThis field is for validation purposes and should be left unchanged.
