2013 Cerebral Palsy Awareness Event

Cerebral Palsy Awareness Event 2013

CDC’s National Center on Birth Defects and Developmental Disabilities, University of Alabama at Birmingham, and United Cerebral Palsy of Greater Birmingham invite you to join us for an event featuring
Stephen Dantzig, PsyD
School psychologist, professional photographer, and author of
Get Up, Your Bus is Here: Living My Life with Cerebral Palsy

Tuesday Evening, March 26, 2013
6:00pm - 7:30pm
LINCPoint at United Cerebral Palsy of Greater Birmingham, 101 Oslo Circle, Birmingham, AL
Doors open at 5:00pm for a book signing and light refreshments.

This event is free and open to the public.

Registration is strongly encouraged. Please complete the form below.

Question Title

* 1. Contact information:
(All fields require an answer to process registration)

First Name: *

Last Name:

Representing (if not applicable please put "n/a")

Address:

City:

State:

ZIP/Postal Code:

Email Address:

Re-enter Email Address: *

Phone Number: *

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* 2. What is your role? (Parent, Provider, Etc.?)

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* 3. Would you like to register additional family members or guests? If you have more than five guests, extra space is available at the end of this form.

Guest 1:

Guest 2:

Guest 3:

Guest 4:

Guest 5:

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* 4. Will you need special accommodations? (Please contact Michael Vaughan if you would like more details on special accommodations. His contact information is below.)

Yes

If yes, please specify:

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* 5. How did you hear about this event?

E-mail

Web site

Direct mail brochure

Word-of-mouth

Other

Other (please specify)

Question Title

* 6. Do you have any questions you would like the speaker (Stephen Dantzig) to answer during the event?

Question Title

* 7. Please use this space (if needed) to register additional guests. Please provide each guest's full name.

For questions and additional information, please contact
Michael Vaughan at 205-975-9575 or mvaughan@uab.edu.

Question Title

* 1. Contact information:(All fields require an answer to process registration)

Question Title

* 2. What is your role? (Parent, Provider, Etc.?)

Question Title

* 3. Would you like to register additional family members or guests? If you have more than five guests, extra space is available at the end of this form.

Question Title

* 4. Will you need special accommodations? (Please contact Michael Vaughan if you would like more details on special accommodations. His contact information is below.)

Question Title

* 5. How did you hear about this event?

Question Title

* 6. Do you have any questions you would like the speaker (Stephen Dantzig) to answer during the event?

Question Title

* 7. Please use this space (if needed) to register additional guests. Please provide each guest's full name.

* 1. Contact information:
(All fields require an answer to process registration)