Bullying Workshop Registation Form

Project ACCESS

Bullying and Individuals with ASD Workshop Registration Form

Training Information

A separate registration form is required for each person wishing to attend.

Name of Workshop: Bullying and Individuals with ASD

Date/Time of training: February 26, 2010, 8:00 AM to 3:30 PM

Presenter: Julie Donnelly, Ph.D.

Location: Truman State Office Building, #490 & #492, Jefferson City, MO 65101

Cost: $45 Parents: $35

Registration Fee includes morning and afternoon refreshments; lunch is on your own
Registration deadline is 10 days prior to event. In the case of cancellation, full refund is available if notice is received 7 working days prior to the event. After that, $25 will be withheld to cover registration and printing costs.

Identification Information

First Name:
Last Name:
Title or Position:
School or Organization:

Billing Address

Billing Address:
City:
State:
Zip:

Home Address

Home Address:
City:
State:
Zip:

Contact Information

E-Mail: (Required)
Work Phone:
Work Fax:
Home Phone:

Billing Information

Amount Sent by Mail:
Check Number:
Purchase Order Number:

Please check this checkbox to indicate that you have read and understood the cancellation policy.

Please make checks out to: Project ACCESS and mail to
Project ACCESS/MSU
901 S National Ave
Springfield, MO 65897

If you have not received a confirmation e-mail by one week prior to the training, CALL TOLL FREE:
1-866-481-3841 or email tina333@missouristate.edu for verification of your registration.

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