2018 Trans Cranial Direct Current Stimulation Workshop

1. Registration Information

Title (Mr., Mrs., Ms., Dr., Lt., etc.) *This question is required.

First Name *This question is required.

Last Name *This question is required.

Name appears on badge as *This question is required.

Organization Name *This question is required.

Organization Address *This question is required.

Organization City *This question is required.

Organization State *This question is required.

Organization Zip *This question is required.

Organization Email Address *This question is required.

Organization Phone Number *This question is required.

2. Will you be participating in the working lunch and snacks on Wednesday, March 13th? If so, lunch will be provided by Panera and the landing fee will be $20.00.

Will you be participating in the dinner at A-town bar and grill the

evening of Wednesday, March 13th?

4. Please indicate if you have and dietary concerns or restrictions.

2018 Trans Cranial Direct Current Stimulation Workshop

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