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       Adult or Teen with NLD     

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 SLPA Board, AOTA, and for psychologists.

             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 Professional Development Units through University of the Pacific, Office of Professional and Continuing Education

               Professional Development Units  cover educators from all states except OH, PA, WI, CT, NJ, IA, TN.

          NLDA membership (tax-deductible):

            In addition to above fee(s), your NLDA membership or yearly renewal is required to attend the symposium.

q       $50 (single)

q       $75 (professional/family)

       Registrations not submitted prior to the Symposium either online or by mail will be subject to a $50     

        walk-in registration fee.

 

       TOTAL SYMPOSIUM FEES:  $__________

      Please indicate how you are paying for your  attendance:  

q       Personal Check #                                                   Amount  $________________________

q       School District PO #                                                Amount  $________________________

  Coming Soon: Register ONLINE with a Credit Card.

 

Cancellation Policy:  Refunds will be issued (minus a $40 administrative fee)  if cancellations are advised by written notice to the symposium address below on or before 2-19-05.   No refunds will be issued after 2-19-05.   Substitutions may be made.  Please advise us if someone else will be attending in your place.  

NLDA Symposium      21001 San Ramon Valley Boulevard,  A4 #175,      San Ramon, California 94583

NLDAsymposium2005@excite.com

 

SPEAKERS         HOTEL         CEUS         SCHEDULE     PRESS RELEASE     PARTNERS      

SUE THOMPSON SCHOLARSHIP FUND