Name:
Address:
City: State:
ZIP:

Parent
Teacher
Therapist
Principal
Homeschooler
Counselor
Other:

Ages of children I work with:

Reserve my space for 3 Days! I am a parent:

enclosing $395 and mailing this form to reach you by the early date for registration.

enclosing $425 and mailing this form to reach you by the end date for registration.

Reserve my space for all 5 Days! I am pursuing Professional Certification:

enclosing $565 and mailing this form to reach you by the early date for registration.

enclosing $595 and mailing this form to reach you by the end date for registration.

I am enrolling for (specify start date of session) (xx/xx/xxxx)

Method of Payment:

VISA MasterCard

Card Number: exp date:

Accomodations:

I will be staying at the Country Inn or other hotel and understand that I need to contact the hotel directly to make reservations.

I will not be staying at a hotel.