Judi Sweeney Workshop Registration Form
(pre-registration is required)
Name: ______________________________________________________________________________
Agency/School: ______________________________________________________________________
Address: ___________________________________________________________________________
City, State, Zip: ______________________________________________________________________
Day Phone: __________________________ Evening Phone_____________________________
Accommodations requested: __________________________________________________________
(Requests for accommodations must be received by Sept. 9, 2005)
Register early, as workshop space is limited.
You will receive confirmation of registration by mail.
RIDE Professional Development Credits will be available.
Please return this form with payment by October 1, 2005.
We regret we are unable to process refunds.
Fee : $150
Payment method:
r Check enclosed
r PO# _______________________________________________________________________________
Please mail or fax copy of po form
r Credit Card # ________________________________________________________________________
Name of Card Holder: ___________________________________________________________________
Expiration Date: _______/________/________ Mastercard/Visa (please circle one)
Please print form, fill in and mail with check payable to:
TechACCESS of RI
110 Jefferson Blvd., Suite I
Warwick, RI 02886
Please contact Beverly with any questions:
Voice/TDD: 401-463-0202, Instate: 800-916-8324 or
email: techaccess@techaccess-ri.org