Last 4 digits of SSN for CEU purposes:_______________ Mr. Mrs. Ms. Dr. _______________________ First Name _________________________ Last Name _________________ Degree   Parent   School Administrator   Counselor   Psychologist Special Educator  Pediatrician Child Psychiatrist Attorney Healthcare Professional   Other Professional____________________________________________________________ Street Address: __________________________________________________________________ City: ___________________ State: ____________________ Zip Code: ______________ Home Telephone # ___________________ Business Telephone # ________________   Email address for confirmation: _____________________________________________ I would like to be made aware of other Solutions Symposia by email   POSTMARKED BY AUGUST 15TH, 2003 -Parent Early Bird Registration Fee (Registration includes two Wrightslaw books valued at $60.00) & _________$130.00 per attendee -2nd Parent in the same family Registration Fee *only available until 8-15-03!!! (NO BOOKS INCLUDED) Name: __________________________________   OR _________$70.00 per attendee Professional Early Bird Registration Fee (Registration includes two Wrightslaw books valued at $60.00)   _________$140.00 per attendee POSTMARKED BY AUGUST 16TH, 2003 AND BEYOND -Parent Regular Registration Fee (Registration includes two Wrightslaw books valued at $60.00) OR   _________$140.00 per attendee Professional Regular Registration Fee (Registration includes two Wrightslaw books valued at $60.00)   _________$160.00 per attendee CONTINUING EDUCATION / CLE CREDITS *must be registered at PROFESSIONAL RATE* _________$20.00 per attendee Total: $________________ Payment may be rendered by personal or business check to Solutions of Hickory, PA Check card, Visa, or MasterCard payments may be made below: MC Visa CkCard Card # __________________________ Exp.#___________________ If address above is not credit card billing address, please provide here: _______________________________________________________________________________________

Mail registration to: Solutions of Hickory, PA
1333 2nd St. NE, Ste. 312 • Hickory, NC 28601 • 828.328.4313 • 828.328.4820 fax
*Limited parent scholarships available. Please email info@solutionsofhky.com for more information.
Conference registration is non-refundable. Substitutions will be permitted.

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