REGISTRATION Advances in Autism Conference Sunday, October 6, 2013
THREE WAYS TO REGISTER
LAST NAME, FIRST NAME
Fax completed registration to 212-828-4221
Online at www.seaverconference2013.eventbrite.com
Mail this form with your check to:
CREDENTIALS (MD, PHD, RN, ETC.)
Seaver Autism Center Icahn School of Medicine at Mount Sinai One Gustave L. Levy Place, Box 1230 New York, NY 10029 Attn: Jessica Brownfeld
ADDRESS
CITY, STATE, ZIP
Enclosed is my check for $ The Seaver Autism Center
TELEPHONE
payable to
Please note that registration will not be processed unless accompanied by payment. E-MAIL
Bill my credit card $ SPECIALTY
■ Visa
■ Mastercard
■ American Express
INSTITUTION/AFFILIATION CARD #:
REGISTRATION INFORMATION FEE
EXP DATE
■ Practicing Physicians, Health Care Professionals, & Educators
$175
■ Mount Sinai & Affiliated Faculty
$125
■ Fellows*, Residents*, Family Members, & Students
$85
CARD HOLDER NAME (please print)
SIGNATURE
* Letter required from Program Director A limited number of scholarships to attend the conference are available.
WORKSHOP SESSIONS Please select the desired workshop you wish to attend. Afternoon Workshops 3:00PM – 4:30PM ■ WORKSHOP A Psychosocial Interventions in Autism Spectrum Disorders: From Research to the Community
CANCELLATION POLICY For conference and registration information, please e-mail jessica.brownfeld@mssm.edu or call (212) 241-0349.
ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI SEAVER AUTISM CENTER FOR RESEARCH AND TREATMENT
■ WORKSHOP B Current Trends in the Pharmacological Treatment of Autism: A Panel of Experts
■ WORKSHOP C Transitioning Across the Spectrum: A Focus on Education, Residential Opportunities, and Day Programming
Please indicate special dietary needs: ■ Kosher ■ Vegetarian
Visit our website at www.seaverautismcenter.org