HAPPY, SAFE, HEALTHY & DIGNIFIED RESIDENTS WITH DEMENTIA

Irwin, PA, Westmoreland Co. - Juniper Village at Huntington Ridge
(formerly Cordia Commons)
(724) 863-2600
Thursday, June 28, 2007
$119.00

St. Marys, PA, Elk Co. - Gunners Inn
(814) 834-2161
Friday, June 29, 2007
$142

*I offer a $20 discount for each additional registrant from the same facility/company.

Seminar Registration Form:

Today’s date:_______________________________________
(Please print name exactly as you wish it to appear on your Certificate of Attendance)

Attendee 1:_________________________________________

Attendee 2:_________________________________________

Attendee 3:_________________________________________

Attendee 4:_________________________________________

Facility Name:________________________________________________________

Mailing Address:_______________________________________________________

___________________________________________County:___________________

Facility Phone:________________________________________

Facility Fax:__________________________________________

Seminar date/city attending:_____________________________

Price per attendee: (#1)______________ (#2)______________

(#3)_____________ (#4)____________ TOTAL:$__________

Method of Payment:____________________________________