The Impressionable Interview for SLPs

Saturday, July 26, 2014 9:00 a.m. to 3:00 p.m.

University of Toronto, Room TBA
500 University Ave, Toronto.
Name:

_____________________________________________________

Address:

_____________________________________________________
_____________________________________________________

Phone:

_____________________________________________________

Email:

_____________________________________________________

Workshop includes Continental breakfast, lunch; and Workbook

Registration
Free to OSLA Student (if staying in Ontario) : New Practitioner 18-month
Membership commencing October 1, 2014 Pay half-price for 6 months ($67.50 +
HST = $76.27) then pay the New Practitioner rate from April 1, 2015 for 20152016 membership year ($135.00 + HST= $152.55).
Student member leaving Ontario or other professional interested in attending
$ 135 + HST = $152.55.
Credit Card Payment: If paying by credit card, please complete the following:
B

Visa

MasterCard American Express

Card Number____________________________________________________ Expiry _____/_____

Cardholders Name __________________________________________________
Authorized Signature ______________________________________________________________
B

Payment by Cheque: If paying by cheque, please send this completed form and cheque to:
U

OSLA, 410 JARVIS STREET, TORONTO, ON M4Y 2G6

OSLA HST #108090879

Auto Renew Option: By selecting the auto renew option, your membership will be
automatically renewed in March of each year at the Early Bird rate.
PLEASE FAX THIS FORM TO OSLA AT 416-920-6214; OR SCAN AND EMAIL TO MAIL@OSLA.ON.CA
________________________________________________________________________________________________________
410 Jarvis St, Toronto ON M4Y 2G6 416-920-3676 / 1-800-718-OSLA (6752) Fax: 416-920-6214 mail@osla.on.ca
www.osla.on.ca