Canadian Stuttering Association (CSA) International Stuttering Awareness Day - Registration Form

Sunday October 21, 2007

Room 235, 500 University Ave. Toronto

Name (First): ___________________________________

(Last): ____________________________________

Mailing Address: __________________________________________________________________________

City: ____________________________________

Province / State: ___________________ 

Postal / Zip Code: _________________

Country (if outside Canada): ____________________________

E-mail address: _____________________________________________________________

Tel:  (        ) _______  -  ____________   HOME                                             

Tel:  (        ) _______  -  ____________   WORK                                 

ARE YOU?

_____ Adult (over 18) who stutters

_____ Teenager (over 12) who stutters  

______ Parent of a person who stutters

______ Speech Language Professional

______ Other –please specify _________

Names and ages of children coming:

Registration Fee – includes juices, coffee, tea, fruit and refreshments

PLEASE BRING YOUR OWN HEALTHY BAG LUNCH

Pre-registered by October 15^th, 2007:

$20 per person or family,  $5 for students

Please make cheques payable to Canadian Stuttering Association and mail with this form to:

Room 160, 500 University Avenue, Toronto ON M5G 1V7

At the door, if space allows:

$25 per person or family, $5 for students