CRAFTING CONNECTIONS - Pre-Order Form



2011 Autism Partnership Workshop Registration Form

Teaching Social Skills that Change Lives: Developing Meaningful Relationships

|Name |

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|Address City State Zip Code |

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|Home Phone ( ) |Mobile Phone ( ) |

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|Email address |Parent, School, Agency or other |

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|Profession |CEU’s: Indicate which CEU’s are needed and provide license # if applicable |

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|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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