ANNUAL SPRING LUNCHEON AND SELECTIVE MUTISM WORKSHOP

First Name: Required

Last Name: Required

District/Agency:

Street Address:

City:

Phone: Required

Email: Required

Are you interested in serving as an Executive Board member for 2017-18? Yes No

Payment Options:
 Professional (SLP, Psychologist, Teacher, etc.) - $75.00
 Retiree - $55.00
 Student - $30.00

Meal Options:
  Breast of Chicken Florentine
  Broiled Salmon, Lemon Bruere Blanc
  Grilled Vegetable Brochette with Wild Rice
*requests for gluten free can be prearranged

Scholarship Donation: (Optional)

PAC Donation: (Optional) - NOT Tax Deductible

Verification: Required
What is 2 x 2?  

Cancellation Policy: Written notice of cancellation must be received by the deadline. No refunds will be made after that time. $10.00 processing fee will be deducted from the refund.