Registraton Form

 

Home Accessible Home - May 15, 2007

Enrollment limited register early. Registration Deadline May 5th, 2007

Duplicate for additional persons. One form per person. Please print.
Name  
Organization/Business  
Address  
City   State   Zip  
E-mail address  
Telephone (day)  
Telephone (evening)  

Return this form to:
Center for Adult and Continuing Education Misericordia University 301 Lake Street
Dallas, PA 18612

Please charge registration fee to my VISA MC Discover Card
Card Number :   Expiration Date  
Person's Name as it appears on the credit card  
Card Holder's Signature  

Conference fee of $65 per person includes lunch and all workshops.

Group rate of three or more is $60 per person. Special rate for seniors and students $30. Price includes CEUs.

Names of others in group must be listed for discount to apply. I am registered with (please include separate registration form for each):
Organization Name
   
   
   

 

 

This should be in the right column.