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PRIMARY CONTACT INFORMATION:
NAMES OF ADDITIONAL PEOPLE REGISTERING:
__________________________________
__________________________________
__________________________________
__________________________________
REGISTRANT IS: (please check all that apply)
Parent
Special educator / paraprofessional
Physical, Occupational, or S/L Therapist
Genetics professional
Psychologist / behavior therapist
Nurse, physician
Social Worker
Other
REFUND POLICY: Conference fees will be refunded, less a $20.00 charge per person, if requested by 2/1/2010. No refunds will be given after that date. |
CONFERENCE FEES
- Registration fee includes all sessions and materials,
breakfast and lunch on Saturday and Sunday.
- All rates are in US dollars.
- Discounted registration is offered for groups
of 3 or more people registering together.
Check all that apply
$ 90 per family member 14 years or older
$100 per person for 1 or 2 non-family registrants
$ 90 per person for 3 or more registering together
TOTAL NUMBER OF PEOPLE ATTENDING
TOTAL PAYMENT
PAYMENT OPTIONS
Check / money order payable to Elwyn Genetics
Bill my credit card for total amount Name as it appears on credit card:
Type of card:
Visa
Mastercard
Card number:
Exp. Date:
Print completed page and mail or fax registration form with credit card information or check / money order payable to ELWYN GENETICS to:
GENETIC SERVICES AT ELWYN
111 ELWYN ROAD, ELWYN, PA 19063
ATTN: BRENDA FINUCANE, MS, CGC
Phone: 610-891-2313
Fax: 610-891-2377 |