Registration form pdf - Autism Society West Bengal

REGISTRATION FORM
Master Trainer Programme towards developing Skills related to
Technology to train individuals with Autism Spectrum Disorders
Organized by: Autism Society West Bengal
Conducted by Prayas: A computer and iPad Training Center;
Venue: Mangalam Business Center’, 6th Floor, 22 Camac Street, Kol- 700016
Workshop Dates: 13th, 14th , 15th February 2015
ASWB Member:
□Yes □No
Registration No:.....................….............
(for office use)
Name: ….………….............................................................................………………………………………………….…....................
Residential Address:..................................................................................................................................................
.......................................................................................
Pin code/Zip................................................................
Mo/ Tel...........................................................Email:......................……....................................................................
For Parents:
Name of Child ________________________________________________________ age _________________
Do you require Child Care:
□Yes
□No
Amount you are paying for child care Rs:________________________________________________________
Contact no. for emergencies __________________________________________________________________
For Professionals:
Organization:..................………………………………………………..……… Designation:.....................………………
Address:................................…………….……………………………………………………………………………….…….........
................................................................................................................
Pin code/Zip.......................
Tel/ Mobile:......................................................Email:................................................
Autism Society West Bengal D/1/1A Katjunagar, Kolkata – 700032 Tel: 033 64581576, Mo: 9830139173 Email: [email protected] Web:
www.autismsocietywb.org
Registration
th
Early Bird (Before
th
4 February, 2015)
After 4 February,
2015
On Spot
th
(13 February, 2015)
ASWB Members
Rs.4000 /-
Rs.5000 /-
Rs.5500 /-
ASWB Non Members
Rs.4500 /-
Rs.5500 /-
Rs.6000 /-
Child care
Rs.200 /- (per day)
Rs.200 /- (per day)
Rs.200 /- (per day)
Registration only on availability of seats. Kindly book your seats on time to avoid disappointment.
PAYMENT DETAILS:
Payment Mode:
□Cash
□Demand Draft/cheque (in favour of Autism Society West Bengal)
DD/cheque no.:............................................................................................ Dated:..........................................
Online Transaction/Demand Draft No: .......................................................... Dated:......................................
Drawn On: ...........................................................................………………………………………………………………............
Total Amount: ...........................................................................……………………………………………………………….......
I understand and accept that:
• The registration fee for each event includes reading material, lunch and refreshments.
• Expert consultation at pre conference will be available only on first come first serve basis to those registered for the pre conference
workshop.
• Demand draft may be drawn in favour of ‘Autism Society West Bengal’ payable at Kolkata.
• Online bank transfer may be made to:
Beneficiary: Autism Society West Bengal
Bank: Axis Bank Limited
IFSC Code: UTIB0000253
Savings A/C No: 910010027520081
•
•
•
•
Registration is non-refundable. In the event of cancellation, it will not be possible to either refundor adjust fee against other services at
ASWB.
Participants will make their own arrangements for travel, boarding and lodging.
Incomplete registration forms or registration forms not accompanied with the registration fees will not be processed.
Please attach a copy of your receipt / demand draft / online transaction receipt along with this form.
PLEASE NOTE : ASWB will not provide laptops therefore Attendees will need to bring their own Laptops;
Completed forms with registration fees may be delivered to:
Workshop Coordinator, Autism Society West Bengal D/1/1A Katjunagar, Kolkata – 700032 Tel: 033 64581576
Please attach a print/scanned copy of your demand draft / online transaction receipt along with the form
Signature______________________________
Date ___________________________________
Autism Society West Bengal D/1/1A Katjunagar, Kolkata – 700032 Tel: 033 64581576, Mo: 9830139173 Email: [email protected] Web:
www.autismsocietywb.org

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