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REGISTRATION FORM FOR INTENSIVE TOILETING
WORKSHOP : PROMOTING INDEPENDENT TOILETING ACROSS THE SPECTRUM
Date: February 26th 2010
RESCHEDULED FOR MARCH 5 2010 Due to Weather
Time: 10 to 1
Location: Elija House 665 N Newbridge Rd
Levittown NY 11756
_____ # of Attendees @ $40 each OR $50
if LATE OR WALK IN FEE AFTER MARCH 1 2010
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
(March 1, 2010)
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:
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
EMAIL US QUESTIONS-> info@effectiveinterventions.com (do not email any "reserve request" )
