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
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

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" )