Monday, January 10, 2011

Registration form for Akron Celiac Disease Conference March 5, 2011

Registration Form
Pre-registration is required. Space is limited.

Registration Form

Celiac Disease Conference and Vendor Fair
Saturday March 5, 2011

Saturday March 5, 2011
Adult Program, Teen Program, School Age Children Program
11:00 noon – 4:30 p.m.
Parent and Child Program for Preschoolers and Young Children
11:00 noon – 3:00 p.m.

Family Name ___________________________________

$ 15 for each adult and
$10 for each child.
Make Checks payable to: Celiac Disease Conference CSA 111

Teens (13-adult) ____
School age (6-12) _____
Preschoolers _____
(Every preschool child must be accompanied by an adult for the entirety of their program )

Total number of family members registering______________

Total enclosed $ ___________

Please list first names and age groups for each family member below.
If you would like a confirmation that your registration has arrived please list your email or phone number clearly below.

See you on March 5th!

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