Training sessions I plan to attend:
____ 1/26/09 ____3/16/09 ____ 5/18/09 ____7/20/09 ____ 9/21/09 ____11/9/09

Personal Information:

Name (please print) _________________________________________________________

Spouse name (if spouse is also attending) _________________________________________

Address: _________________________________________________________________

City, State, Zip code: ________________________________________________________

Telephone: ___________________________ Email ________________________________

I am a: ___ parent, ___ teacher, ___ speech therapist, ___ OT, ___ PT, ___other

Please mail your registration to
Interventions Unlimited, Inc.
848 Executive Drive, Oviedo, Florida 32765
or fax the form to (407) 678-8885

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