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REGISTRATION FORM FOR 1 DAY WORKSHOP : Introduction to Autism & ABA & how it applies to teaching children with Autism
Time: 10 to 2
Location: 665 N. Newbridge Rd. Levittown NY 11756
Select your date: _______ October 24 2008 or ________November 21, 2008
_____ # of Attendees @ $45 each(includes lite refreshments)
Total amount enclosed $________
THOSE WITH DIETARY RESTRICTIONS ARE KINDLY ASKED TO BRING THEIR OWN LUNCH.
Consider your canceled check as your confirmation, $25.00 cancellation/bounced check fee, Considered late and NON REFUNDABLE 1 week prior to date of workshop
Name (s) _______________________
_______________________________
_______________________________
Address _________________________
_______________________________
Phone ______________________ Email_______________________
Organization or Affiliation (ie: Parent,Speech,Teacher)_____________________
Send Check or Money Order Payable to:
EFFECTIVE INTERVENTIONS
665 Newbridge Road Levittown NY 11756
We also take Visa/Mastercard (circle one) Acct#____________________________ Exp Date:________
Card Holders Signature: _____________________________
Phone:516 433 4202 Fax 516 433 4324 (for information or questions only. Do not fax a reg form)
EMAIL US QUESTIONS-> info@effectiveinterventions.com (do not email any "reserve request" or email reg forms)
