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KING OF PRUSSIA, PA - REGISTRATION FORM
(Please complete a separate registration form for each individual attending)
*All of the following information is for use by this office ONLY. We do not distribute or sell our information.
PLEASE PRINT
Title Dr.
Mrs.
Ms.
Mr.
Name (First/Last)
Mailing Address
Organization (if business address)
Street
PO Box
CityState/Zip
Telephone (
)
Email
*Please PRINT.
Please check: Psychologist
Parent
Social Worker
SLP
Teacher
Administrator
 Other (please specify):
Student
Please register me for the following:
 King of Prussia, PA Conference (November 6, 2015) ~ $175 ~ Zones of Regulation
TO REGISTER OR TO ASK QUESTIONS:
ON-LINE (Credit Card)
www.MapleLeafCenter.com
By FAX (Purchase Order or Credit Card)
Fax (802) 446-3802
By PHONE (Credit Card)
(802) 446-3601
By MAIL: Check payable to Maple Leaf Center, 270 Olde Pine Lane, Wallingford, VERMONT, 05773
CREDIT CARD INFORMATION:
VISA  
Mastercard
AMEX 
Discover
Card Number:Expiration Date:
Security Numbers:
Name as it Appears on Card:
Seating will only be reserved once your FULL payment (Purchase Order, Check, Credit Card) has been received.
REFUNDS: Requests for refunds must be made in writing. A full refund, less a $25 service charge, will be made for requests
postmarked by FRIDAY, OCTOBER 23rd. NO refunds will be made thereafter.
Maple Leaf Center is not responsible for any presenter's or participant's statements, acts, materials, or omissions. Videotaping and
audiotaping is prohibited. Hand-held audiotaping is permitted with written request prior to the conference only as an accommodation
under the ADA. If you have any special dietary needs or if you require special accommodations due to a disability, please contact the
office so that we may provide you with appropriate service.
Whether you are traveling from near or far ~ safe travels ~ we look forward to seeing you.