Healthcare Conference Registration Form

Building an Autism Friendly Practice
April 3, 2020 (Boston Medical Center, 820 Harrison Avenue, Boston MA 02118)
The conference is designed for healthcare professionals (staff, clinicians, trainees, students, administrators) from any discipline or practice setting, seeking to create/strengthen an organization’s ability to serve patients with Autism Spectrum Disorder (ASD).
Name*
First NameLast Name
Title
Professor, Dr, Ms, Mr, etc.
Email*
example@example.com
Phone Number*
Country CodeArea CodePhone Number
Will you be seeking CEUs?*
Yes - Nursing (note: $10 surcharge)Yes - Social Work (note: $10 surcharge)No
Do you have any dietary restrictions?
Please briefly explain what brings you to this training.
Has your organization already undertaken any "Autism Friendly" efforts? If so, please explain.
(Optional) Job Title:
(Optional) Employer:
Upon submission of this form, please mail a check for $125.00 ($135.00 if collecting CEU), payable to "The Autism Program at Boston Medical Center" to:

The Autism Program at Boston Medical Center
c/o Alexander Friedman
801 Albany Street, Floor 1E
Boston, MA 02119

Confirmation will be e-mailed upon receipt.

Please contact autismfriendly@bmc.org or visit us with any questions or concerns.
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Building an Autism Friendly Practice