Registration Form Currently this form can not be submitted online but you may fill out the form below online and PRINT the completed form to mail or fax.
Registration must be postmarked by September 30, 2008
(Registrations postmarked after 9/30/08 will only be accepted if capacity is not reached)
Please fill in the form fields below and click "Print" at the bottom of the page when you are done. Once the form is printed, please be sure to sign and mail or fax the completed form to the contact information listed below.
I am a: Professional Student Family member KKI employee
Please select which workshops you will be attending:
One-day attendance for professionals (October 23 or 24) $185
I will be attending (check one): October 23 October 24
Two-day attendance for professionals (October 23 and 24) $350
One-day attendance for families of children with autism, students, and KKI employees (verification required for students) $135
I will be attending (check one): October 23 October 24
Two-day attendance for families of children with autism, students, and KKI employees (verification required for students) $260
Please make checks payable to Kennedy Krieger Institute REACH or pay by credit card.
Visa MasterCard
Card Number: Exp. Date:
Signature on Card:
Name of Registrant:
Organization:
Address:
City:
State:
Zipcode:
E-mail:
Phone:
Fax:
I am Seeking: ASHA CEU's OT CEU's Psychology CEU's No CEU's (you will receive a certificate of attendance)
Preferred Method of Registration Confirmation: U.S. Mail E-mail Fax
After printing the form, you must sign below
Signature:______________________________________________
Once you have completed the form, please click the button below to print the page
Complete this registration form and Fax 443-923-7560 or mail to:
Kelly Templeman
Kennedy Krieger Institute
Center for Autism and Related Disorders
3901 Greenspring Avenue, Baltimore, MD 21211
templeman@kennedykrieger.org
Cancellation Policy: All cancellations must be confirmed in writing and postmarked no later than October 1, 2008. No refunds will be given for no-shows. A $35 administration charge will be applied to all cancellations.
