Mail-in Registration Form

Childhood Apraxia of Speech: More Questions Than Answers?
Dr. Sandra Schneider
Friday, May 3, 2013

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, breakfast, lunch and refreshments.

This conference is offered for .55 ASHA CEUs (Intermediate level, Professional area) and for .5 Michigan State Board CEUs.

$30 Student Registration
$55 Registration
$65 Registration and .55 ASHA CEUs (Intermediate Level, Professional area).
$65 Registration and .5 MI State Board CEU
$75 Registration and BOTH .55 ASHA and .5 MI State Board CEUs
Notes, comments, or questions:

Cancellation Policy: Cancelled registrations will be refunded, less a $15 cancellation fee if cancelled before April 26, 2013.

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