Name* First Last Email* Phone*I am requesting CEUs (for SLPs)* Yes No PricingIndividual: $35.00Family: $45.00SLP-CEUs: $85.00Grad. students: $25.00Wake County rateSpecial SLP registration (with client's family): $50.00Price will increase by $5 after 02/02/2019Billing Address (credit card)* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How many children will you be bringing*012345Below, please specify name, age, and if child stutters or if they're a sibling. ex. Maria, 10, stutters ex. Tommy, 8, sibling ex. Mike, 13, sibling Name, age, stutters/siblingName, age, stutters/siblingName, age, stutters/siblingName, age, stutters/siblingName, age, stutters/siblingPlease check all that apply:* I am an adult who stutters I am a parent I am an SLP I am a student Other How did you hear about this conference?Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Total $0.00 Above total is based on the One-Day Conference you have chosen to attend, and the type of registration. Refund Policy: Registrations may be refunded up until 24 hours prior to the conference. Please send an email to kevin@friendswhostutter.org to initiate a refund.EmailThis field is for validation purposes and should be left unchanged.
