Families As Partners 2008 Conference Registration
Please note that you will not be registered for the conference until this form is received with full payment. Please
complete and return this registration from along with payment to the Office of Special Programs, 82 Washington
th
Square East, 5 Floor, New York, NY 10003-6680. Fax: 212-995-4923. Phone: 212-992-9380
Please make a copy of this form for your records.
1. NAME:
2. EMAIL:
(First)
(M.I)
(Last)
3. TITLE:
4. AFFFILIATION
5. PROFESSION: __________________________________________________________
6. MAILING ADDRESS:
(Street)
(City)
7. BILLING ADDRESS:
(If different than above)
(Apt. #)
(State)
(Street)
(City)
(Zip Code)
(Apt. #)
(State)
(Zip Code)
8. DAYTIME PHONE: ______________9. NIGHTTIME PHONE:
10. CELL PHONE:
Meal requirement
__I request a kosher meal
Conference Fee: $25.00
Please check all that apply:
th
__I am attending the Town Hall Meeting on Tuesday March 4
th
__I am attending the Families as Partners Conference on Wednesday March 5 (fee of $25)
I will pay by:
___Credit Card
___Check
Credit Card Payment ___ Visa ___MasterCard ___American Express
Total Amount Authorized: $ ___________________________________________
Credit Card Number: ___________________________________________
Expiration Date: Month ________ Year________
Cardholder’s Signature: Date ____________________
11. CONFERENCE PAYMENT ENCLOSED: $
(You may pay with credit card or a personal check made out to New York University)
Check Payable to:
New York University
Office of Special Programs,
th
82 Washington Square East, 5 Floor
New York, NY 10003-6680