REGISTRATION FORM FOR July 9, 2008 Dr. Robert Coben
Topic : EEG Operant Conditioning as a treatment for Autistic disorders
_____ Number of ELIJA Member Registration(s) @ $50.00
_____ Number of Non Member Registration(s) @ $75.00
(includes bagel breakfast and boxed lunch )
Due and non refundable after July 2nd 2008
THOSE WITH DIETARY RESTRICTIONS ARE KINDLY ASKED TO BRING THEIR OWN LUNCH.
***Consider your cancelled check as your confirmation, $25.00 cancellation/bounced check fee
Total amount enclosed $________
Name (s) _______________________
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Address _________________________
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Phone ______________________ Email_______________________
Organization or Affiliation (ie: Parent,Speech,Teacher)_____________________
Send Check or Money Order Payable to:
The Elija Foundation
665 Newbridge Road Levittown NY 11756
We also take Visa/Mastercard (circle one) Acct#____________________________ Exp Date:________
Card Holders Signature: _____________________________
Phone:516 433 4321 Fax 516 433 4324 (for information or questions only. Do not fax a reg form)
EMAIL US -> Elija@optonline.com (do not email any "reserve request" or email reg forms)
