Professional Development School Age Children Who Stutter 2.8.2019

Name*
First Last
Title
Organization / Company
Organization / Company Address
Street Address Address Line 2 City State ZIP Code
Email
Phone
Billing Address*
Same as previous

Street Address Address Line 2 City State ZIP Code
Credits Applying for:
- Act 48
- ASHA
- NBCC
- Psychology Credits
- SW, MFT, & PC
Professional ID number
Event Cost
Price: $100.00
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Registration begins 1/2 hour prior to stated program time. Cancellations made LESS THAN 72 HOURS before the programs will NOT be refunded.*
- I have read and understand CORA’s cancellation policy.