Please provide the following contact information:
An asterisk (*) indicates a required field.

*First Name

Clinical Instructors are eligible to receive an

*Last Name

additional 25% off their continuing education

Discipline

registration. Contact Kaci Rieker to request

*Mailing Address

this offer at 405-271-2131 ext. 47110.

Address (cont.)

*City

*State/Province

*Zip/Postal Code

*Daytime Phone

Evening Phone

Fax Number

E-Mail Address

Priority 1

Code 

Priority 2

Code  

Priority 3

Code  

Priority 4

Code  

Priority 5

Code  

Priority 6

Code  

Method of Payment

Check
(Please mail check with a completed copy of this form and any additional documentation)
Credit Card
(Please follow instructions after form is submitted)

Mailing Address:
OUHSC
Department of Rehabilitation Sciences
Attn: Kaci Rieker
1200 N Stonewall
Oklahoma City, OK 73104

Questions?
Call Kaci Rieker at
(405) 271-2131 ext. 47110 | Fax: (405) 271-2432

PLEASE PRINT THIS FORM PRIOR TO SUBMITTING!



A confirmation will be sent via email once payment is received. Thank you!

For additional information, please contact: Kaci Rieker
or call (405) 271-2131 ext. 47110