REGISTRATION FORM FOR Peter Gerhardt Ed.D
Presentation of : Transitioning into Life
July 18, 2008 - Marriott Residence Inn - Media Center 3rd Floor 9 Gerhard Road Plainview NY 11803
_____ ELIJA MEMBER Registration(s) ... $40.00
_____Non ELLIJA Member Registration ...$50.00
_____ LATE AND WALK IN Registration(s) ... $75.00 (includes coffee/bagels and boxed lunch )
Due by July 4 2008 -
THOSE WITH DIETARY RESTRICTIONS ARE KINDLY ASKED TO BRING THEIR OWN LUNCH. Also bring a sweater if you are prone to getting cold
***Consider your cancelled check as your confirmation, $25.00 cancellation/bounced check fee, Non refundable after 7/4/08
Total amount enclosed $________
Name (s) _______________________
_______________________________
_______________________________
Address _________________________
_______________________________
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: _____________________________