Caring in the Carolinas 2021 | Carolinas Society for Post-Acute and Long-Term Care Medicine

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First Name *

Last Name *

Degree/Credentials *

(e.g. MD, DO, CMD, GNP, PharmD, etc.)

Organization/Practice *

Address *

Address 2

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Phone *

Number where you can be reached regarding registration

Email Address *

E-mail where you can be reached regarding membership (this address will not be shared without your permission.)

Cancellation Policy for 2021 CPALTC October Meeting

All cancellations must be made in writing to CPALTC. Notices can be emailed to taclements@novanthealth.org. Cancellations received by October 4, 2021, will receive a full refund less a $50.00 administrative fee. Cancellations received between October 4-11, 2021, will be refunded half of the registration fee. Fees will be refunded the same way they were paid to CPALTC. Please allow up to four weeks for delivery of refund if payment was made by check. Cancellations received after October 11, 2019, will result in the forfeiture of all registration fees. No-Shows will also forfeit all registration fees. Partial or full fees that have been forfeited cannot be applied to subsequent meetings.

Registration Fees *

Member Physican = $125

Non-Member Physician = $240

Member Advance Practitioners and Associates = $100

Non-Member Advance Practitioners and Associates = $175

Payment Method *

Credit card online or PayPal (submit payment on next screen) You do not need a Paypal account for this option.

Check (mail check to Thad Clements ATTN: CPALTC Membership, 8430 University Executive Park Dr., Suite 685, Charlotte, NC 28262 ) payable to CPALTC.

Please select which payment method you will use for your membership dues. If you will be paying online you will need to complete the payment information which will be presented on the next screen after you submit this membership application data form.

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