LDA Member Fee $55.00 $____________Learning Disabilities
Association of Maine
PROUD to be THE MAINE STATE AFFILIATE of LDAA www.LDAAmerica.org
Registration Form LDA of Maine Annual Conference CEU = 8 Contact Hours
SCHOLARSHIPS may be available for LDA MEMBERS who are PARENTS of school-age students with Specific Learning Disabilities & for ADULTS with SLD/LD who pre-register by 11.14.09.
Call toll-free 1-877-208-4029 or Email info@LDAme.org
DISCOUNT: LEA/Districts save 10% when you register 5 or more personnel together before 11-14-09.
PRE-REGISTRATION FEES Deadline 11-14-09 (includes registration fee, lunch & full day attendance).
Check one:
LDA Member Fee $55.00 $____________
Non-Member Fee $95.00* $____________
College Student Fee $15.00 (with copy of Sttudent ID) $____________
High School Student accompanied by paid attendee (pre-registation required) $ FREE! FREE! FREE!
Student Name:_______________________________ School: __________________________________________
STUDENT SESSION 1 Choice (Circle One): A. B. C. D. E PART 1
STUDENT SESSION 1 Choice (Circle One): E. PART 2 F. G. H. I.
ON-SITE REGISTRATION does not include lunch: WALK-IN REGISTRATION ONLY AFTER 11-14-09
Check one:
LDA Member Fee $85.00 $____________
Non-Member Fee $175.00* $____________
College Student Fee $25.00 (with copy of Student ID) $____________
LDA does not give out personal information to third parties without a signed Release Form.
Attendee Name_______________________________ LDA member # ____________ Expiration Date: _______ *
Address__________________________________City___________________________ State______ Zip________
Phone: Home: ___________ Work: ____________ Cell: _______________Email_____________________________
Session 1 Choice (Circle One): A. B. C. D. E PART 1
Session 2 Choice (Circle One): E. PART 2 F. G. H. I.
*Not a member? Add $35.00 & Register as a Member of BOTH LDA of Maine & LDA of America!
_____ YES! I am sending an additional $35.00 for membership with my registration fee.
PURCHASE ORDERS (payment due within 30 days): FAXES ACCEPTED (207) 465-4844. You will not be invoiced unless payment is not received by December 22, 2009; invoices have a $35 Processing Fee.
PO # ________________ Contact Person: ______________________________________________
LEA/DISTRICT: ___________________________________________Phone: __________________
PAYMENT: REMIT check, money order, purchase order to:
LDA OF MAINE
P.O. Box 67 Oakland, Maine 04963
TEL: Toll Free In-state 1-877-208-4029 or (207) 465-7700
FAX: (207) 465-4844 info@LDAme.org WEB SITE: www.LDAme.org