AD/HD Conference Registration Form
January 27, 2007
(Snow Date: March 10, 2007)
Space is limited.
Registration from 8:00 to 8:45 a.m.
                               CONFERENCE COST:

$20.00 Individual
$25.00 Couple
Free for High School, University Students and WCU faculty


Pre-registration is now closed!  We will be accepting walk-in registrations the
morning of the conference.
Check all that apply:
Parent/Teacher/Professional (Circle one per session)
First Session                      A        B        C
Second Session                D        E        F
Adults with ADHD Track
 College Issues Track
Act 48 Credits
 Student/WCU Faculty (Free)
Name:  _________________________________________________________________

PIN# or Soc Sec No: _______________________________________________________

Address:  _______________________________________________________________

School District: ___________________________________________________________

City/State/Zip:  ___________________________________________________________

E-Mail:  _________________________________________________________________
Charge my:
 VISA
 M/C
 AMEX
Account #__________________________________         Expiration date:_________

Name (as it appears on card) ________________________

Signature __________________________________

                   The deadline for receipt of mail registration is January 12, 2007.