CRAFTING CONNECTIONS - Pre-Order Form
2011 Autism Partnership Workshop Registration Form
Teaching Social Skills that Change Lives: Developing Meaningful Relationships
|Name |
| |
|Address City State Zip Code |
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|Home Phone ( ) |Mobile Phone ( ) |
| | |
|Email address |Parent, School, Agency or other |
| | |
|Profession |CEU’s: Indicate which CEU’s are needed and provide license # if applicable |
| | |
|How did you hear about this workshop? |
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September Workshops
Please fax completed form to (562) 431-8386 or email to workshops@
| September Dates |Hotel Information |Fees* |# of |
| | |Early/Regular |Participants |
|September 12, 2011 |Hilton Embassy Suites - Boston Logan Airport 207 Porter Street, |$85/100 | |
|BOSTON |Boston, MA 02128 | | |
|September 14, 2011 |Hilton- New York - 1335 Avenue of the Americas |$85/100 | |
|NEW YORK |New York, NY, 10019 | | |
|September 16, 2011 |Arlington Court Suites Hotel 1200 N. Courthouse Rd., |$85/100 | |
|WASHINGTON D.C. |Arlington, VA 22201 | | |
|September 17, 2011 |Hilton - Atlanta - 255 Courtland Street NE, |$85/100 | |
|ATLANTA |Atlanta, GA 30303 | | |
|September 19, 2011 |Hurst Conference Center -1601 Campus Drive |$85/100 | |
|TEXAS |Hurst, Texas 76054 | | |
|September 21, 2011 |University of Colorado- Denver School of Medicine |$100/115 (lunch | |
|COLORADO |Anschutz Medical Campus -13121 E. 17th Avenue Building l-28 Education 2 South Room 1102 |included) | |
| |Aurora, CO 80045 | | |
|September 22, 2011 |Holiday Inn & Suites 506 West Harrison Street |$85/100 | |
|CHICAGO |Chicago, IL 60607 | | |
|September 23, 2011 |Hilton St. Louis at the Ballpark - One South Broadway, |$85/100 | |
|ST. LOUIS |St. Louis, MO 63102 | | |
*Early Registration (by August 31st, 2011)
Registration Fee Includes: A copy of Crafting Connections, CEU’s for ASHA, BACB, MCEP, BBS
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Payment Method
Credit Card: Master Card: Visa: American Express Discover Check _ _
(If paying by check: make check out to Autism Partnership and mail to 200 Marina Drive, Seal Beach, CA 90740 or fax to (562) 431-8386 or email form to workshops@)
Credit Card #: [pic][pic][pic][pic] / [pic][pic][pic][pic] / [pic][pic][pic][pic] / [pic][pic][pic][pic]
3-4 digit code (usually found on back of card) [pic][pic][pic][pic] Expiration Date: [pic][pic]/ [pic][pic]
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