Summer Intensive
Auditory Rehabilitation Conference

Registration Form and Cost

Please submit your information as soon as possible as registration is limited!

Tuition scholarships are available!
Send in registration forms by May 1, 2007 for scholarship consideration

PRINT this page, COMPLETE form and SEND to:

SIARC Attn: Linda Thibodeau
UTD/Callier Center
811 Synergy Park Blvd.
Richardson, Texas 75080

Name:

______________________________________________
Address:
______________________________________________ 
Phone:                City:                                         State:
____________      _______________________     ______
Zip:                      Date of Birth: 
____________       _______________________
 

Please complete the following questions:

   1) Current Hearing Aid User?  YES [ ]   NO [ ]
        If yes,
            1) How long have you worn hearing aids?
                  _______________________________

            2)  Do you wear one [ ] or two [ ] hearing aids?

  2)  Will you require any special accomodations
          during  the conference?  YES [ ]  NO [ ]
          If yes, please describe:
          ________________________________________
          ________________________________________
          ________________________________________

  3)  Do you have any diet restrictions or special
           diet needs?  YES [ ]   NO [ ]
           If yes, please describe:
           ________________________________________
           ________________________________________
           ________________________________________

Significant Other's Name:

______________________________________________
Address:
______________________________________________ 
Phone:               City:                                        State:
____________     _______________________     _______
Zip:                    Date of Birth: 
____________     _______________________
 

    Please complete the following questions:

   1) Current Hearing Aid User?  YES [ ]   NO [ ]
        If yes,
            1) How long have you worn hearing aids?
                  _______________________________

            2)  Do you wear one [ ] or two [ ] hearing aids?

  2)  Will you require any special accomodations
          during  the conference?  YES [ ]  NO [ ]
          If yes, please describe:
          ________________________________________
          ________________________________________
          ________________________________________

  3)  Do you have any diet restrictions or special
           diet needs?  YES [ ]   NO [ ]
           If yes, please describe:
           ________________________________________
           ________________________________________
           ________________________________________