NAMES OF ALL BEING REGISTERED:

STREET_________________________

CITY____________________________

STATE/ZIP_______________________

PHONE__________________________

COMPANY_______________________

Enclosed is my check for the following type of registration:

 

___Professional ($60)

 

___Brain Injury Survivor ($25)

 

___Family Member ($25)

 

___Survivor & One Family Member ($40)

 

___BIAD Supporter ($35)

RSVP by October 12, 2005.  Late registration will be assessed a $5 penalty.  Scholarships are available to assist those in need.  Call us to make a request at 1-800-411-0505.

Please make check payable to:

Brain Injury Association of DE, Inc.

 Send check & registration form to:

Howard Hitch, Conference Registrar
PO Box 807
Ocean View, DE 19970

 Survivor I.D. Cards available     Nursing CEU’s applied for