DSHA Fall CONFERENCE 2011 REGISTRATION FORM
Friday, October 28, 2011
Clinical Management of Language and Short Term Memory Impairments in Aphasia
by: Nadine Martin, Michelene Kalinyak-Fliszar, Francine Kohen
Please print and mail this form with a personal check payable to DSHA on or before October 8, 2001 to:
Kathy Vacek
917 Aster Ave,
Newark, DE 19711
Name: _______________________________________
Address: _____________________________________
_____________________________________________
Telephone: ____________________________________
Email address: _________________________________
Affiliation: _____________________________________
DSHA Member: ($110) ____________
Non-member ($145) _______________
Late Fee ($25) __________________
Total: $ ______________________
*Application to DSHA may be completed on the day of the program. Fees refundable with notice of cancellation on or before October 8, 2011. Confirmation notice will be mailed after receipt of your registration. Registrations postmarked after October 8, 2011 will be assessed a $25 late fee.
Registration is limited and is not complete without payment.