JOIN US FOR
MENTAL HEALTH DAY AT THE CAPITOL
Sponsored by the
Behavioral Health Services Coalition
THURSDAY, MARCH 4, 2010
The Georgia Railroad Freight Depot
Martin Luther King, Jr. Drive at Central Avenue
(near the Coca-Cola Pavilion at Underground Atlanta)
Proposed Program Schedule
8:15 A.M.-9:00 A.M. Registration
9:00 A.M. - 12:00 P.M. PROGRAM
12:00 P.M. Lunch with Legislators and
Consumer Art Show
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To pre-register, fax this form to the attention of Rheba Smith at 404-758-6833, or email to Rheba at rheba.smith@gpsn.org. In the event you are pre-registering, you will be required to have payment ready when you check in on the day of the event. It is YOUR responsibility to make sure payment is received.
To register and send payment now, please make checks payable to GEORGIA PARENT SUPPORT NETWORK and send to Rheba Smith, GPSN, 1381 Metropolitan Pkwy., Atlanta, GA 30310, or fill out the credit card information below. Credit card payments MUST be accompanied by a daytime phone number. Please, one person per form. Rheba can be reached at 404-758-4500 if you have concerns.
Yes! I/we will attend; $25 registration fee PER PERSON is enclosed.
I/we will attend as a consumer or family member; $20 registration fee per person is enclosed.
______I would like to apply for a consumer/family scholarship (FREE of cost to consumers and family members).
______I am enclosing a donation to support Mental Health Day
at the Capitol $_____.
ORGANIZATION NAME__________________________________
INDIVIDUAL'S NAME
ADDRESS_____________________________________________
CITY____________________ STATE____ ZIP_______________
PHONE_________________EMAIL_______________________
CHECK OR CREDIT CARD NUMBER: ______________________________________EXP._____________
NAME ON CARD: __________________________________ 3-DIGIT V-CODE ON BACK: _______
TOTAL AMOUNT TO BE CHARGED: $_______ SIGNATURE: _________________________________________
