Speaking Out! 2008
CONFERENCE SPONSORSHIP FORM
Please note that your sponsorship will not be valid until this form is received with full payment. Please
complete and return this registration form along with payment to the Office of Special Programs, 82
th
Washington Square East, 5 Floor, New York, NY 10003-6680 or by fax: 212-995-4923. Phone: 212-9929380
Please make a copy of this form for your records.
SPONSOR CONTACT INFORMATION:
Name:
Organization:
Address:
E-mail:
City/State/ZIP:
Daytime phone:
Evening phone:
Please indicate the fees you would like to include in your sponsorship:
Full conference Registration:
Optional Activities:
(Please indicate number of registrants you
(Please indicate number of registrants you would
would like to sponsor)
like to sponsor)
Professional*
Optional Banquet, June 20
Early Bird: $415 per person
$50 per person, for conference attendees
After May 1, 2008: $430 per
person
$85 Banquet ONLY
----Audrey Holland, Pre-Conference Workshop
Survivor and/or Co-survivor
ONLY*
Early Bird: $175 per person
$250 per person, Professional (0.6 CEU)
After May 1, 2008: $190 per
$100 per person, Students and
person
Survivors/Co-survivors
Students and NSSLHA members
Early Bird: $175 per person
After May 1, 2008: $190 per
person
Total amount due:
IF YOU WISH TO SPONSOR A SPECIFIC INDIVIDUAL OR INDIVIDUALS, PLEASE INCLUDE
THEIR NAME (S) AND CONTACT INFORMATION:
Name:
Organization:
Address:
E-mail:
City/State/ZIP:
Daytime phone:
Evening phone:
Name:
Organization:
Address:
E-mail:
City/State/ZIP:
Daytime phone:
Evening phone:
METHOD OF PAYMENT
___ Check enclosed (payable to: New York University)
___ Credit card: ___Visa or ___MasterCard #: ___________________________________________
Expiration date: ______________________
Signature: _______________________________________
SPONSORS
This conference is co-sponsored with the NAA
by:
♦ NYU Steinhardt’s Department of SpeechLanguage Pathology and Audiology
♦
Web site:
http://steinhardt.nyu.edu/conference/aphasia2008
Contact: The Office of Special Programs at New
York University, Michelle Lagos at 212-992-9380
or email at [email protected]
The National Aphasia
Association
350 Seventh Avenue Suite
902
New York, NY 10001
800-922-4622
Fax: 212-267-2812
www.aphasia.org
The National Aphasia
Association thanks the
Rehabilitation Institute
of Chicago, for support
through grant number
H133B031127 from the
National Institute on
Disability and
Rehabilitation
Research, United States
Department of
Education, Washington,
D.C.