S.I.A.R.C. 2001 REGISTRATION
JULY 16-21, 2001
 

PRINT this page, COMPLETE form and SEND to:

Linda Thibodeau
UTD Callier Center
1966 Inwood Road
Dallas, TX 75235



 
 
 

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:
           ________________________________________
           ________________________________________
           ________________________________________

 
 
 
 
 
 
 
 

PAYMENT INFORMATION:

Conference Price: $350.00 (2 Persons)*
*Price does not include hotel accomodations, please
call or e-mail for special hotel rates and reservations

Method of Payment:
[ ] I wish to pay by check and have enclosed a check for $350.00.
[ ] I wish to pay with the following credit card:

MasterCard [ ]    Visa [ ]     American Express [ ]    Discover [ ]

Card #: __________________________ Exp.Date: _______

Signature:__________________________  Amount:   $350.00








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REMINDER!!

WHAT:   S.I.A.R.C. 2001

WHEN:    July 16-21, 2001

WHERE:    1966 Inwood Road
                    Dallas, TX 75235

PHONE:   214-905-3000 (ext. 3108)

E-MAIL:    thib@utdallas.edu