REGISTRATION FORM
NLDA’s 9th Annual Symposium
March 11-12, 2005
This form must be entirely completed and submitted with your payment.
First Name_______________Initial___ Last Name____________________Title______
Email Address
Company
Address
City_________________________________State Zip
Day Phone (_____)______________________
Evening Phone ( __)
Registration Fee (includes lunch):
q $140 Friday only, postmarked by 2-19-05
q $160 Friday only, postmarked after 2-19-05
q $140 Saturday only, postmarked by 2-19-05
q $160 Saturday only, postmarked after 2-19-05
q $230 Both days, postmarked by 2-19-05
q $280 Both days, postmarked after 2-19-05
I am a(n) ?.. (check all that apply)
q Educator
q MFT
q Nurse
q Occupational Therapist
q Parent
q Physician
q Psychologist
q SLP
q Social Worker
q Other
Continuing Education Credits:
CMEs provided by CA Chapter 1 of the American Academy of Pediatrics (AAP)
CEUs provided by CA BBS (pending), CA SLPABoard
q $25 for 1- or 2-day participation
CMEs cover medical professionals.
CEUs cover psychologists, LCSW, MFT, SLP, OT
q No Charge for attendance forms (available at Symposium) for ProfessionalDevelopment Units through University of the Pacific
ProfessionalDevelopment Units cover educators from all states except OH, PA,WI, CT, NJ, IA, TN.
NLDA membership (tax-deductible):
Inaddition to above fee(s), your NLDA membership or yearly renewal is requiredto attend the symposium.
q $50 (single)
q $75 (professional/family)
Registrations not submitted prior to the Symposium either online or by mail willbe subject to a $50
walk-in registration fee.
TOTAL SYMPOSIUMFEES: $__________
Please indicate how you are paying for your attendance:
q Personal Check # Amount $________________________
q School District PO # Amount $________________________
ComingSoon: Register ONLINE with a Credit Card.
Cancellation Policy: Refundswill be issued (minus a $40 administrative fee) if cancellations are advised by written notice to the symposiumaddress below on or before 2-19-05. Norefunds will be issued after 2-19-05. Substitutions may be made. Pleaseadvise us if someone else will be attending in your place.
NLDASymposium 21001 San Ramon Valley Boulevard, A4 #175, San Ramon, California 94583