Date:

Name:

2nd Attendee's Name:

Organization:

Address:

City: State: Zip Code:

Phone: Home: Cell:

Work: Fax:

Email address:

Please Check All That Apply: I am a: Parent Family Member Caregiver/Guardian Self-Advocate

Educator Attorney Social Worker Professional Counselor Service Provider Other:

Applying for 14 Continuing Legal Education credits - no charge **Must register as a professional**

Applying for 1.2 Continuing Education Units - $18.00 payable at conference

Registration:
Parent $125.00 (includes books, 1 breakfast, 1 lunch each day)
Teacher / School district employee $125.00 (includes books, 1 breakfast, 1 lunch each day)
School District Position Grade Level (if applicable)
Couple $175.00 (includes one set of books per household, breakfast for 2 people, lunch for 2 people each day) *must reside at same address*
Professional $175.00 (includes books, 1 breakfasts, 1 lunch each day)
2nd professional from same agency $125.00 (includes one set of books per agency, 2 breakfast for 2 people, 2 lunches for 2 people each day)
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I will send a check to Special Students of Hernando, P.O. Box 12271 Brooksville, FL 34603

I will pay for my registration via credit card using PayPal  (see button on conference information page)

****Registration is not complete until payment is made / received****
             Seat not guaranteed until payment is received

I will need an "original" receipt for payment - available at the conference for pick up

Do you require any accommodations while attending the conference? If so, please indicate;