Workshop 2015 REGISTRATION FORM
Alzheimer’s – Lighting the Way
Sponsored by
SOUTHERN NEW JERSEY
Two locations
NORTHERN NEW JERSEY
Wednesday, April 15, 2015
Fee: $75 (after March 18 $100)
Student Fee: $45 with valid ID
No refunds after March 25
Friday, May 15, 2015
Fee: $75 (after April 18 $100)
Student Fee: $45 with valid ID
No Refunds after April 25
RiverWinds Community Center
1000 Riverwinds Drive
West Deptford, NJ 08086
Ph: 856-251-0990
Children’s Specialized Hospital
150 New Providence Road
Mountainside, NJ 07092
Ph: 888-244-5373
Registration is limited please register early
Please Circle a location: SOUTHERN NJ or NORTHERN NJ
Personal information will not be shared
NAME: __________________________________________________________________________
(Please print clearly - only one name per form)
AGENCY/ORGANIZATION: _________________________________________________________________PHONE (Work): _______________________
ADDRESS: ____________________________________________________________________________________PHONE (Home): ______________________
CITY: ______________________________________________ STATE: __________ ZIP: _______________ CP/Em. #: ______________________________
E-MAIL: (Work) ________________________ __________________
(Home): _____________________________________________________________
In case of emergency please check preference of contact
SPECIAL ASSISTANCE REQUIRED: (Must notify NJCRID by March 18th for Southern NJ Workshop and April 18th for the
Northern NJ Workshop)
A.S.L. Interpreter
Dietary, please specify: ___________________________________________
CONTINUING EDUCATION:
5.0 PDUs - Available for Educators & 0.5 CEUs (No additional cost).
Registering for CEUs
Registering for PDUs
FORM OF PAYMENT:
(Make checks payable to: NJCRID)
Check #: _________________________________
Amount $____________
Purchase Order #: ______________________
Kindly enclose this form with payment to:
Amount $____________ (Must be received by March 10 for
Southern NJ and April 10 for Northern NJ)
Alzheimer’s/LTW
c/o NJCRID
PO Box 26
Kendall Park, NJ 08824
Credit Cards will be processed by PayPal through the link on www.njcrid.org
Written notice is required via email ([email protected]) to withdraw registation for refund prior to the above deadlines.