This is our online 2 Step Application
to join our On Line Programs
STEP #1)
Complete this form with all of your current information
STEP #2) Mailing & Payment Instructions follow on Step #2
page After you hit
the Submit button at the end of this form,
you can pay with a Charge Card Online with our
Secure PayPal account or send your Check via US Mail Summer Special Training Reg. $149
• $99.00 Lessons* with 8 Clock Hours of credit *Includes Online Book and Online Caregiver Training Video
• $10.00 Read My Book On Line
• $10.00 Watch My Video On Line •
(NOTE: Prices subject to change without notice. Call for current prices) All Shipping & Handling charges listed on this site are based on shipments made within North America (USA & Canada)
NOTE:You MUST Complete the Required fieldsto submit this application form
Your
Name: Required
Address: Required
City:
State: Required
ZIP Code:
Phone
Number(s): Required
Home Cell
Your Email
Address: Required
Create your personal Password: Required Needed to Log-In to our online lessons area
User name: your real name will be used all lower case/no spaces - i.e. johnsmith Password
(Minimum 6 characters, NO Spaces - Letters&Numbers Only)
Password
(Re-Type your Password)
Select Product: Required
On Line Lessons with 8 Credit Hours ($149.00$99)
Read My Book On Line ($10.00)
Watch My Video On Line ($10.00)
Payment
Method: Required
Personal Check to follow via Postal Mail
Charge
online via our Secure PayPal account
(Your Payment Method is Required for Program Registration) Step #2 has options for payment via US mail or PayPal
Today's
Date
Double Check all your information
BEFORE clicking submit above Thank
You
Remember STEP #2) After you hit Submit My
Application you can
Pay OnLine via our Secure PayPal account or send your Check to: Alzheimer Activities Services c/o Amira Choukair Tame, ACC P.O. Box 250313 West Bloomfield, MI 48325 Make checks payable to Alzheimer Activities Service
(Must be received within 10 days of application) Please put your FULL NAME as listed above, in the message area on your Check Summer Special Training Reg. $149 *$99.00 Lessons with 8 Clock Hours of credit
*Includes Online Book and Online Caregiver Training Video
$10.00 Read My Book On Line
$10.00 Watch My Video On Line
(NOTE: Prices subject to change without notice. Call for current prices) All Shipping & Handling charges listed on this site are based on shipments made within North America (USA & Canada)
Amira
Choukair Tame, ACC
Address:
Alzheimer Activities Services
P.O. Box 250313 West Bloomfield, MI 48325
