Mail-in Registration Form

Autism and Us: Balancing the Social Teeter Totter
Laurel Falvo, CFLE
Friday, November 30, 2012

Please fill out and print the registration form below. Send one registration form per person along with your payment to the address below. Payments should be check or money order made payable to Calvin College.

If you would like to register with a credit card, please use our secure online registration form at Please note that a small processing fee will be added to online registrations.


Registrant Information

First Name:
Last Name:
Email Address:
Home Address:
Job Title:
Institution Address:
Preferred Address: Home
Daytime Phone:
First and last name as you would like it to appear on the nametag:

Special Needs

Do you have any special needs (dietary, accessibility, or other)? If so, please list.
How did you hear about this conference?

Registrant Contact List

During the conference, we will provide all registrants with a list of names and contact information for all who attend.

I give permission for my name and contact information to be made available to all registrants.

Registration Options

Pre-registration is required. Registration includes conference materials and refreshments.

This conference is offered for .3 ASHA CEUs (beginning level, professional area). State Board CEUs are not offered for this event.

$20 Registration
$10 Student Registration
$30 Registration and .3 ASHA (American Speech-Language-Hearing Association) CEUs
Notes, comments, or questions:

Cancellation Policy: Cancelled registrations will be refunded, less a $15 cancellation fee if cancelled before November 23, 2012.

If you have any questions, please contact us at:
Seminars @ Calvin
1855 Knollcrest Circle SE
Grand Rapids, MI 49546-4402
(616) 526-8558