TO REGISTER: PRINT OUT THIS FORM AND 
			CALL: 800-985-1752
			FAX TO: 888-206-5081

			OR MAIL TO:	VISION EDUCATION SEMINARS
					151 SUMMIT LANE
					BALA CYNWYD, PA 19004
 
 
Workshop Location: _________________________________________

Name _______________________________________________________

Address: ___________________________________________________

	 ___________________________________________________

City _____________________________ State _____ Zip__________

Day Phone (        ) _______________________________________

Email Address ______________________________________________

_____ Both Days _____ Day one only

_____OT _____ PT _____ Speech _____ COTA _____PTA ______Other

o enclosed is my check payable to Dr. Mitchell Scheiman 

o I have also enclosed $70 for Understanding and Managing Visual Deficits

o I have also enclosed $73 for Low Vision Rehabilitation

o Visa    o MasterCard    o American Express   o Discover Card

Card #: ______________________________ Exp date__________ Security Code: _____________