Payment Information for Parents

Checks should be drawn in U.S. dollars, payable to CHERAB Foundation. On the memo line, please write "for EFA and Apraxia Conference".

Please mail your checks and completed
registration form to us at our mailing address.
Credit Card payments must be sent by mail or fax.

Print the completed registration form, along with your credit card information (below).

1.
Mail the completed registration form and credit card information

OR

2.
Fax the completed registration form and credit card information
Required Credit Card Information: (Please print this form)

Card Type:
Card Number:
Expiry Date:
Name on Card:
Billing Address1:
Address2:
(Include Zip Code)
Comments/Special Instructions
Festive Dinner featuring Dinner Speaker, Hugo W. Moser, MD. "Emerging Therapies for Neurologic Disorders"
Dinner. . . . . . . . . . $50.00 per person
. . . . . . . . . . . . . .($100.00 per couple)