Ages and Stages®, LLC Workshops for SLPs, OTs, and Others    
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PEDIATRIC COURSE REGISTRATION FORM
Mail to: Ages and Stages®, LLC
11390 Patores St.
Las Vegas, NV 89141
Fax to: 702-914-3414
Phone: 702-845-0642

Name (Print)_______________________________
Address___________________________________
City________________State________Zip_______
E-mail address______________________________
Phone_____________________________________
Occupation_________________________________
Employer__________________________________

Enclosed is the workshop fee of
$325 or $299 (early registration 3 weeks prior)

  HOUSTON, TX – February 26 & 27, 2010
  BATON ROUGE, LA – March 5 & 6, 2010
  MEMPHIS, TN – April 16 & 17, 2010
  LITTLE ROCK, AR – April 23 & 24, 2010
  PITTSBURGH, PA – May 14 & 15, 2010
  COLORADO SPRINGS, CO – June 25 & 26, 2010

Checks should be made payable and sent to:
Ages and Stages®, LLC 
11390 Patores Street
Las Vegas, NV 89141

For credit card payments:
  VISA    Mastercard  Discover
Credit Card #_____________________________
V-Code (last 3 digits on back of card) _______
Exp. Date ________________________________
Your Signature___________________________
Address above needs to be same as card

o School or business Purchase Order attached
o Discount $10 pp. 3 or more registering together

Confirmation will be sent by e-mail unless otherwise requested.

Refund or Cancellation:

A full refund will be given up to two weeks prior to the workshop less a $25 processing fee. After that date no refunds will be given but amount may be applied to any future workshop.

Ages and Stages®, LLC reserves the right to cancel this workshop for insufficient registration or unforeseen circumstances. Cancellation of workshop will result in a full tuition refund. However, Ages and Stages®, LLC will not be responsible for financial loss due to cancellation including airline and hotel accommodations.

Reasonable accommodations will be made for individuals with disabilities. Please contact us if you need special consideration.