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Next Steps into Adolescence Workshop - Mail Registration (Please Print)
Name(s): _____________________________________________________________________
_____________________________________________________________________
Organization: _________________________________________________________________
Title: ________________________________________________________________________
Check One:
___ I am a parent/caregiver ($25.00 registration fee)
___ I am a professional and would not like continuing education units ($45.00 registration fee)
___ I am a professional and would like continuing education units ($75.00 registration fee)
Check one: ____ Psychology ____ Act 48 ____ Social Work
Address: ___________________________________________________________________
E-Mail _____________________________________________________________________
Phone: _____________________ญญญญญญญญญญญญญญญญญญญ________________ Amount enclosed: ________________
Please enclose your check payable to: The Children's Hospital of Philadelphia Please write Center for Autism Research in the MEMO line
Return form and check to: Gail Stein Center for Autism Research 3535 Market Street - Suite 860
Philadelphia, PA 19104
If you have any questions, please contact: Gail Stein, MSW Center for Autism Research (CAR) at The Children's Hospital of Philadelphia autism@email.chop.edu 267-426-4910 |