On-Line FEAT/RI 2008 Conference Registration Form

*Denotes required fields.

Date:

New Member:     Current Member

Select registration type:

FEAT RI MEMBER (Parent/TA) = $60.00
NON MEMBER (Parent/TA)= $85.00
Conference and 1 YEAR Parent MEMBERSHIP = $80.00

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FEAT RI MEMBER (Professsional) = $135.00
NON MEMBER (Professional) = $175.00
Conference and 1 YEAR Professional MEMBERSHIP = $150.00

Full Name*:

Street Address:
City:   State:   Zip Code:

Home Telephone:   Work Phone:
Fax:   Email*:

Agency Affiliation/ABA Provider:

Select your payment method (continues on next page after application is submitted):

I will me making using the PayPal online payment system.

I will be mailing a check for payment (no credit cards by mail).

Click the Submit button, below, to continue your application onto the PayPal Page: