REgistration

Home Address - Street____________________________City _____________ State ______ Zip Code __________

Home Telephone ( _____) ____________ Fax ( _____)_______________E-mail:_______________________

Street Address _______________________City ______________________ State ________ Zip ___________

School/Business Phone ___________________________Fax ____________________E-Mail:________________________

Thursday Pre-Symposium Workshop 8 am – 4 pm (lunch included)	$150.00	Add $50.00	Add $100.00
Thursday evening banquet, Friday and Saturday (lunch included both days)	$325.00	Add $50.00	Add $100.00
All Events: (Pre-Symposium Workshop, Thursday Evening w/ Buffet, Friday and Saturday…lunch included all three days)	$425.00 (save $50.00)	Add $50.00	Add $100.00
___ I am joining NLDA for the first time for the membership fee of $50.00 - individual; $75.00 - family; $75.00 - professional (Please add this membership fee to your total amount)
Total Amount Due------------------------------------------------------------------------
PERSONAL OPTIONS Choose one from each time slot: Friday 7 AM Facilitated Conversations: a Life Skills b How to Lead An NLDA Support Group (with booklet) c Getting Organized d Handwriting e IEP's 1:30 - 3:00 PM F1 Dr. Herb Schreier and Coleen Dorfman, Ph.D. F2 Jacqueline Earle-Cruckshanks, MS MA F3 Robert Crockett F4 James Callner, MA F5 Michelle Garcia-Winner, MA, CCC 3:15 - 4:45 PM F6 Rondalyn Whitney, MOT, OTR and Robin Bonsall, OTR F7 Kathryn Stewart, Ph.D F8 Shreve Archer, MD, FAAP F9 Kelli Bond F10 Judy Freedman, L.C.S.W. Saturday 7AM Facilitated Conversations: a Siblings b NLD Coaching as a Successful Intervention c Helping Parents Make a Therapies' Plan d NLD Adults e Fair Hearings 10:30 AM - Noon S1 Meryl Lipton, MD, Ph.D S2 Schools Panel S3 Rondalyn Whitney, MOT, OTR S4 Marcia Rubinstien, MA S5 Bernadette Evans, Ph.D. 2:45 PM - 4:15 PM S6 Michelle Garcia-Winner, MA, CCC S7 Meredith Warshaw, MA S8 Kathy Allen, MA S9 Tim Derning, Ph.D. S10 Teen Panel
Return this page with check payable to: NLDA, 21001 San Ramon Valley Blvd. A4 #175, San Ramon, CA 94583 Be sure to send a self-addressed stamped envelope with your form and check. Cancellation policy: Refund (minus $25) if NLDA is notified in writing prior to 3/15/01 School purchase orders will be accepted (include individual registration forms) CEU's pending acceptance of application. Certification of completion will be issued for interested professionals. For further information, call NLDA (in California) (925) 820 4079; (in Connecticut) (860) 693 3738, or email: [email protected] You may also call the NLD Hotline (831) 624-3542 or visit www.NLDA.org or www.NLDline.com

Confirmation will be sent to you upon receipt of registration form and payment.

DoubleTree Symposium Room Rates are $129.00 (special group rate) plus tax for any size bed, single or double occupancy. To make reservations call toll free at 1-800 222 8733 or by calling the DoubleTree directly at (831) 649-4511. To receive this special group rate, be sure to mention NLDA. Reservations must be made by March 15, 2001. Reservations must be made with a major credit card and there is a 24 hour cancellation period.. Cancellations will be accepted until 24 hours prior to your arrival date. Check-in Time is 3:00 p.m. and Check-out Time is 12:00 noon. There is an airport shuttlebus from San Francisco and San Jose Airports (approximately 1 hour south of SF) that leaves for Monterey eight different times during the day: From SF: 6:45am, 9:20am, 12:05pm, 2:50pm, 5:35pm, 8:20pm, 10:45pm. The fee is $30.00 one way.

NLDA's 5th ANNUAL PROFESSIONAL SYMPOSIUM REGISTRATION FORM

(please complete a separate photocopied form for each person, if there is more than one individual attending)