Dementia 2001 Registration Form

*First Name____________________ *Last Name________________
Nickname, Handle, Screen Name, Etc. _____________________
*Address:________________________________
Address:________________________________
*City:___________ *State:_______ *Zip: ___________
Phone: (____) ____ - ______
E-Mail:________________________________________
DOB: _____/_____/_____

* Required 
How would you like confirmation of registration?

[ ] E-mail
[ ] Postcard

Pre-Reg (before feb,1 01) - $35.00
At the door - $40.00 

Please send check or money order to....
Please make checks payable to: Bill Putt

Dementia 2001
21136 Greenhill Rd.
Farmington Hills, MI 48335