TO REGISTER: PRINT OUT THIS FORM AND CALL: 610-664-5270 FAX TO: 888-206-5081 OR MAIL TO: VISION EDUCATION SEMINARS 151 SUMMIT LANE BALA CYNWYD, PA 19004 Workshop Location: _________________________________________ Name _______________________________________________________ Address: ___________________________________________________ ___________________________________________________ City _____________________________ State _____ Zip__________ Day Phone ( ) _______________________________________ Email Address ______________________________________________ _____ Both Days _____ Day one only _____OT _____ PT _____ Speech _____ COTA _____PTA ______Other o enclosed is my check payable to Dr. Mitchell Scheiman o I have also enclosed $36 for Dr. Scheiman’s book o Visa oMasterCard o American Express o Discover Card Card #: ______________________________ Exp date_______