Canadian Stuttering Association (CSA)
International Stuttering
Awareness Day - Registration Form
Sunday October 21, 2007
Room 235, 500 University Ave.
Toronto
Name (First):
___________________________________ (Last): ____________________________________
Mailing Address:
__________________________________________________________________________
City:
____________________________________
Province / State: ___________________
Postal / Zip Code:
_________________
Country (if outside Canada): ____________________________
E-mail address:
_____________________________________________________________
Tel: ( ) _______ -
____________
HOME ARE
YOU?
_____ Adult (over 18) who stutters
_____ Teenager (over 12) who stutters
Tel: ( ) _______ -
____________
WORK ______Parent
of a person who stutters
______Speech
Language Professional
_____ Other –please specify _________
Names
and ages of children coming:
$20 per person or
family, $5 for students
Please make cheques payable to Canadian Stuttering Association and mail with this form to:
Room 160, 500 University Avenue, Toronto ON M5G 1V7
$25 per person or family,
$5 for students