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Applied Psychology
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Continuing Ed
Coaching Individuals with Asperger Syndrome
Please print, fill out, and mail this form to:
Lucy Marsh,
Department of Applied Psychology
Antioch University New England
40 Avon Street
Keene, NH 03431-3552
Please sign me up for Coaching Individuals with Asperger Syndrome:
___December 3 - 4, 2008 ___April 2 – 3, 2009
First Name:_____________________________________________________________________ Last Name:______________________________________________________________________ Occupation:_____________________________________________________________________ Company Name:___________________________________________________________________ Mailing Address:________________________________________________________________ City/State/Zip:_________________________________________________________________ Day Phone Number:__________________________________ Evening Phone Number:______________________________ Email:_____________________________________________
This workshop includes one book (check one):
____Asperger Syndrome: An Owners Manual (ages 10–15)
____Asperger Syndrome: An Owners Manual 2 for Older Adolescents and Adults
Fees
Professional fee: $389
Discount rate per person for family members of an individual on the
Autism Spectrum:$359
Late registration fee, within 14 days of the event: $419
Checks and purchase orders accepted. Antioch Tax ID #310536640.
Checks should be made payable to Antioch University New England.
Check enclosed $_______________ Purchase order enclosed $_______________
© 2007 Antioch University New England, 40 Avon Street, Keene, NH 03431-3516 800.553.8920