Let's Have a Potty Party- A Potty Training Workshop

REGISTRATION FORM:

Name: ________________________________________________________

Address: _____________________________________________________

Phone #: _____________________________________________________

About your child/person you are attending for:

(parent, sibling, therapist, teacher, etc., INCLUDE THE AGE AND DISABILITY OF THE INDIVIDUAL- if applicable) ________________________________________________________________

Number attending:  _________________

How did you hear about this workshop (be as specific as possible, please J)

________________________________________________________________________________________________________________________________________________           

Cost: 

            _____ Family registration ($25/individual or couple;

$10 for each additional applicant)

            _____ Professional registration ($25/person)

Send completed registration form and check BY APRIL 1, 2008 (made payable to Anderson Behavioral Consulting) to:

Anderson Behavioral Consulting

638 Watervliet Ave.

Dayton, Ohio 45420