REGISTRATION FORM FOR Dr. Bobby Newman's presentation of Toileting Children with Autism.
_____ Number of Registration(s) @ $40.00
(includes lite refreshments )
Due and non refundable after June 13 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) _______________________
_______________________________
_______________________________
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: _____________________________
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)
