The Elija Foundation Proudly Presents
REGISTRATION FORM FOR INTENSIVE TOILETING
WORKSHOP : PROMOTING INDEPENDENT TOILETING ACROSS THE SPECTRUM
Print out this page and Mail/Fax it to us!
Date: June 9, 2010
Time: 10am to 12pm
Time: 10am to 12pm
Location: Elija House 665 N Newbridge Rd
Levittown NY 11756
_____ # of Attendees @ $20 Elija Members $30 Non Members Late/Walk In (after June 3, 2010 is $40)
Total amount enclosed $________
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
(June 3, 2010)
YOU CAN ALSO REGISTER ONLINE BY CREDIT CARD BY CLICKING HERE
YOU CAN ALSO REGISTER ONLINE BY CREDIT CARD BY CLICKING HERE
Name (s) _______________________
_______________________________
_______________________________
Address _________________________
_______________________________
Phone ______________________ Email_______________________
Organization or Affiliation (ie: Parent,Speech,Teacher)_____________________
Send Check or Money Order Payable to:
Elija Foundation
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
EMAIL US QUESTIONS-> info@elija.org (do not email any "reserve request" )