Dementia Practice Guideline Registration Form

American Therapeutic
Recreation Association

Dementia Practice Guideline
Evidence-Based
Competency Workshop

Program Description
May 5, 2006 Syracuse, NY

Instructions: complete this form online. If paying by credit card, press the Continue Button to submit your credit card information on a secure server. If you are planning to mail this application along with your payment, complete this form online and print it out.

Full Name
Job Title
Organization
Mailing Address
City
State
Zip
Phone
Fax
E-mail
Are you a CTRS?	Yes No
Check box if you require special services (diets, handicap accessible rooms, etc) to fully participate?
Please describe your special needs:

Fees:

	early	within 2 wks of workshop
Professional ATRA member	$190	$210	*Includes lunch, breaks and CEUs, as well as copy of the Dementia Practice Guideline (list price $179)
Professional nonmember	$335	$355	*Includes what is listed above, as well as a one year ATRA membership.

*The Dementia Practice Guideline book is required for this course.

Deadline for registration is two weeks prior. On-site registration is limited; please call ATRA to see if space is available. ATRA reserves the right to cancel this workshop if enrollment does not meet a minimum requirement of 20 attendees.

Check day:

Friday May 5, 2006, Syracuse, NY

.7 (7 hours) of CEUs will be awarded. In order to be awarded CEUs, you must attend the entire day

TOTAL FEES ENCLOSED: $
CONFIRMATION Upon receipt of your registration, a confirmation letter will be sent to you that will include directions and additional information on the training site.

Method of Payment:

	Check or Money Order Enclosed (U.S. Dollars / Payable to ATRA)
	Purchase Order #___________________ (A copy of the PO must accompany this registration form.)
	Credit Card: VISA Mastercard Discover
	I authorize payment for the items listed above. Signature: _____________________________
	(NOTE: if paying by credit online, click on the button below to complete the credit card information on a secure server. If sending in your payment and registration form by mail, print this form out.) Credit Card #: ___________________________
	Exp. Date: ______________________________
	Name on Card: ___________________________

Mail with check or money order to:

American Therapeutic Recreation Association
1414 Prince Street, #204
Alexandria, VA 22314

Fax (with credit card or purchase order) to: (703) 683-9431

ATRA, 1414 Prince St. Suite 204, Alexandria, VA 22314 . (703) 683-9420 . Fax: (703) 683-9431
atra@atra-tr.org