7th Annual NJABA Conference
Transcription
7th Annual NJABA Conference
7th Annual NJABA Conference Friday, March 23rd, 2012 Bridgewater Manor, Bridgewater NJ 7th Annual NJABA Conference • The New Jersey Association for Behavior Analysis is proud to sponsor its 7th Annual Conference, to be held at the Bridgewater Manor in Bridgewater, NJ. Visit their website for general information (www.bridgewatermanor.com) and for directions (www.bridgewatermanor.com/direction-card-bridgewatermanor). • NJABA is a non-profit organization dedicated to promoting the advancement of the discipline of behavior analysis and is an affiliate chapter of the Association for Behavior Analysis International (ABAI)TM. • The conference is geared toward administrators, consultants, trainers, direct service providers, educators, and parents who are interested in learning about the principles and applications of behavior analysis for a wide range of learners. • A variety of workshop topics are provided to allow attendees to focus on specific areas of interest related to behavior analysis. • Continuing Education credits, approved by the Behavior Analyst Certification Board*, the New Jersey Department of Education, and the American Speech-Language-Hearing Association**, can be earned through conference attendance. *NJABA is an approved provider of BCBA Type II continuing education credits. The Behavior Analyst Certification Board (BACB) does not sponsor, approve, or endorse NJABA, the materials, information, or sessions identified herein. **NJABA is approved by the Continuing Education Board of the American Speech-Language-Hearing Association (ASHA) to provide continuing education activities in speech-language pathology and audiology. This program is offered for 5.5 CEUs (Intermediate level; Language Disorders Assessment and Intervention). ASHA CE Provider approval does not imply endorsement of course content, specific products, or clinical procedures. Schedule of Events 8:00 - 8:45 AM Check In, On-site Registration, & Continental Breakfast 8:45 - 9:00 AM Introductory Remarks 9:00 - 11:15 AM Keynote Address 11:15 AM - 12:00 PM Poster Presentations 11:30 - 12:15 PM Insurance Roundtable* 12:00 - 12:45 PM Lunch 12:45 - 2:15 PM Early Afternoon Workshops 2:20 - 3:50 PM Late Afternoon Workshops *Overlaps with lunch Keynote Presentation On Being an Applied Behavior Analyst: Behavior is the Limit Alicia M. Alvero, Ph.D. “ABA” is most commonly associated as an excellent tool for use with persons with Autism and other developmental disabilities, but the reality is that ABA is a powerful tool across many populations and settings. The use of ABA within organizational settings is often referred to as Organizational Behavior Management (OBM) or Performance Management (PM). Information regarding the science of OBM and its common applications will be presented. How one can determine if performance deficits are due to problems within the organizational structure or the organizationʼs performance management system will also be examined. This presentation will also examine ways to analyze organizational needs and describe effective interventions to solve common organizational problems. Anthony Cammilleri, Ph.D., BCBA-D Applications of the science of behavior found an early venue in classrooms for typically developing children. As time passed, those applications waned in prominence as applications for children with developmental disabilities surged. Today, applications of the science of behavior are disproportionally allocated to one particular developmental disability—autism. This has led some in the public at large to wonder if ABA stands for Autism and Behavior Analysis (Schlinger, 2011). With applied behavior analytic interventions widely recognized as the treatment of choice for children with autism, this very association has produced some misconceptions in the general public that did not, heretofore, exist. Perhaps chief among them is that behavior analytic technology is autism treatment technology and therefore inadequate to meet the needs of typical learners. This unfortunate misconception may limit the willingness of educators to the use behavior analytic technology with typically developing children. Given the persistent educational problems in the United States, efforts are needed to better inform the public of the power of the science of behavior and the diagnosis-independent status of its applications. One way to do this is to better publicize the few behavior analytic schools and programs that already exist for serving typically developing learners, offer them as examples to emulate, and provide a vehicle for the dissemination of the technology used. The purpose of this talk is to describe the behavior analytic based instructional strategies and system variables in use at Century School in Lawrence, KS (for typically developing children), and the Jane Justin School in Fort Worth, TX (for children with mild to moderate special needs). Michael Himle, Ph.D. Tourette syndrome (TS) involves involuntary motor and vocal tics. One of the more interesting aspects of TS is that tics fluctuate over time and with context. It is well established that tics are the product of specific neurobiological dysfunction and are involuntary. The longstanding medical model has contended that attempts to suppress or alter tics through behavioral processes are ill advised. Accordingly, first line treatments have traditionally involved pharmacotherapy and supportive psychotherapy. However, several recent behavior analytic findings highlight the role of environmental factors, including both automatic and social operant processes, in the course and manifestation of tics. I will briefly review a series of laboratory and clinical studies that demonstrate the role of internal and external environmental factors in tic fluctuation and outline how a series of behavior analytic findings have a) helped to explain important clinical phenomenon in TS (e.g., tic suppression, contextual fluctuation), b) have systematically addressed long-standing myths about TS, and c) have led to important advancements in the conceptualization and treatment of tics. Poster Presentations (11:15 AM - 12 PM) Insurance Roundtable (11:30 AM - 12:15 PM) Registration Not Required Insurance Roundtable Suzanne Buchanan, Psy.D., BCBA-D Do you have questions about maximizing insurance reimbursement? New Jerseyʼs autism insurance mandate has presented behavior analysts with both opportunities and challenges. In the two years since the law went into effect, behavior analysts have been independently learning and negotiating all aspects of the insurance process, e.g., working with insurance carriers, completing forms, understanding relevant policies and regulations. Letʼs learn from each otherʼs experiences. Join other behavior analysts to discuss how to make the most of this process for yourself and your clients. Early Afternoon Workshops/Symposia (12:45 - 2:15 PM) Please Register For One #1 - Using iPads to Enhance Communication Skills of Students with Autism. Kathleen McCabe-Odri & Laura Kenneally Using lecture and video format, this workshop will illustrate how the use of an Ipad, iPod touch, or iphone can increase communication opportunities for student with autism. The presenter will discuss several software programs that help students enhance their communication skills, and increase their opportunities to be included in general educational and the community. #2 - Incident Reports: More than a Document to Cover Your A$$. Paul Argott, Diana Zitelli, & Julia Mandelbaum-Nater Abstract: Incident reports are routinely completed to document the occurrence of an accident or injury at a workplace while the incident is fresh in the minds of the participants. The commonly held reasoning is that incident reports are required to protect a direct-care provider from liability if the accident leads to legal recourse. While this is a valid purpose for the use of incident reports, it is not the only one (Jansma, Wagner, Kate, & Bijnen, 2011); incident reports can be used to guide staff development and training, analyze treatment outcomes, and facilitate change in company policy. This workshop will provide insight on the purposes of completing incident reports, provide suggestions for the sufficient and necessary components when developing an incident report, offer guidance on the appropriate language to use in the report, provide a sample report that can be used as a guide for professionals, discuss the incident report review process, and discuss the follow-up measures that can be taken as a result of incident report review. Discussion will include data on the effects of an incident report created based on these suggests and will provide examples on how the sample report has been used to guide progress in a private school for individuals with autism. #3 - Developing Employment Opportunities for Adults with Autism: What Do I Need to Know to Keep My Job? Gregory S. MacDuff Abstract: The applied literature contains numerous studies that document response classes that adults with autism must display if they are to be successfully employed. This workshop will discuss the role activity schedules and motivational systems play in shaping these key responses. Databased examples of work and life-skills programs will be used to illustrate critical programming variables. Unfortunately, the absence of appropriate behavioral repertoires and occurrences of inappropriate behavior at job sites continue to result in the termination of employment for a large percentage of adults with developmental disabilities. A brief review of the literature will be presented. Often, termination can be prevented through ongoing communication with employers. To ensure the success of PCDIʼs adult learners, employer satisfaction with employees with autism as well as learnersʼ life-skills coaches is assessed through annual consumer questionnaires. The results of these evaluations will be reviewed over a 5-year period. Late Afternoon Workshops/Symposia (2:20 - 3:50 PM) Please Register For One #4 - Relax, Donʼt Restrain! Behavior Relaxation Protocols for Students with Autism and Challenging Behavior. Kathleen McCabe-Odri & Laura Kenneally Abstract: Behavior Relaxation Training (BRT) is a well-documented research-based methodology proven to reduce the physical responses to stress for many groups of individuals, including students with autism (Poppen, 1998). This workshop addresses strategies that have successfully reduced problem behavior across age groups (e.g., preschool through High School students). Through video examples, and objective data of pre- and postintervention, participants will gain knowledge on how to use BRT approaches with their own students. Sample treatment plans, including visual supports, as well as guidelines on how to instruct learners to identify possible functions of their own disruptive behaviors will be presented. #5 - Teaching Weight Management to Children with Autism & Their Parents. Kevin J. Brothers & Debbie Brothers Abstract: The dramatic increase in obesity in the United States in the past 30 years is reflected in the fact that currently two-thirds of adults and nearly one-third of children are overweight or obese (Benjamin, 2010). Children with disabilities may be helped to maintain a healthy weight and Body Mass Index (BMI) throughout their lifetimes when they and their caregivers are taught effective weight-management skills. This presentation reviews the data from a weight-management program designed to teach four children with autism and their parentsʼ skills to establish and maintain a healthy BMI. Three of the four children were in the obese range and one was underweight. The weight management program consisted of teaching portion control, informed meal consumption choices, informed non-mealtime consumption choices, and appropriate activity level. All participants have made progress towards their goal of a healthy BMI. These case studies set the occasion for further investigation with an experimental research design. #6 - Social Skills Interventions for Children with Developmental and Learning Disabilities. Ruth M. DeBar Abstract: This symposium will be comprised of four data-based presentations that describe interventions to teach different types of social skills to children with developmental and learning disabilities. In the first study, the authors implemented a multiple schedule arrangement in public education classrooms to participants who approached their teachers at high rates during independent work time. In the second study, the authors used a multiple probe design across three board games to evaluate the effects of video modeling on social commenting of three children with autism. The third study was an evaluation of an intervention package to teach item-specific mands to children with autism who used generalized mands (e.g., pointing) that resulted in access to a variety of items. The fourth study investigated whether an iPod touch© was effective to teach activity schedule following involving independent leisure activities to four children with autism. 1: Effects of Multiple Schedules on the Social Approaches of Special Education Students in Public Education Classrooms. Elizabeth A. Kraljic, Tina M. Sidener, Sharon A. Reeve, & Kenneth F. Reeve 2: Effects of Video Modeling on Social Commenting During Board Games. Ashley Johnston, Ruth M. DeBar, Sharon A. Reeve, & Tina M. Sidener 3: An Explicit Technology to Teach Item-Specific Replacement Mands to Children with Developmental Delays. Kelly McCarthy, Tina M. Sidener, Vincent Carbone, Ruth M. DeBar, & Kenneth F. Reeve 4: Using Activity Schedules on the iPod touch© to Teach Leisure Skills to Children with Autism. Kelly Carlile, Sharon A. Reeve, Kenneth F. Reeve, & Ruth M. DeBar Presenter Bios Alicia M. Alvero, Ph.D. is an Associate Professor at Queens College, The City University of New York and the Deputy Chair of the Psychology Department. She received her B.A. in Psychology from Florida International University, and both her M.A. in Industrial-Organizational Psychology and Ph.D. in Applied Behavior Analysis from Western Michigan University (WMU). Dr. Alvero was awarded the prestigious Ford Foundation Fellowship while at WMU for her research in behavioral safety and the effects of safety observations. Her research in the areas of performance feedback, behavioral safety, time sampling procedures, and training have been published in peer-reviewed journals such as Professional Safety, the Journal of Organizational Behavior Management, Journal of Applied Behavior Analysis, Journal of Safety Research, Analysis of Verbal Behavior, and Journal of Agricultural Safety and Health. She is the author of several book chapters, and is an editorial board member for the Journal of Safety Research and an Associate Editor for the Journal of Organizational Behavior Management. She has been an invited speaker at numerous conferences across the country. Some of Dr. Alveroʼs current research in the areas of performance feedback and behavioral safety has been funded through NIOSH and PSC-CUNY grants. She also serves as an organizational consultant in the areas of training and development and behavioral safety. Paul J. Argott, Ph.D., BCBA-D is the Clinical Director of the Educational Partnership for Instructing Children. He earned his doctoral degree from the Graduate Center of the City University of New York in Psychology with a focus on Learning Processes and Behavior Analysis and a specialization in developmental disabilities. He has presented at local conferences and the annual ABAI conference on the social skill development and language production of individuals with autism. His clinical and research interests include the empathic responding and vocal productions of individuals with autism, the use of reinforcement schedules to modify behavior in applied settings, and behavioral variability as an operant. Debra A. Brothers, BSN, RN, earned her Bachelorʼs degree in 1984 from Wilkes University. In 1983 she was inducted into Sigma Theta Tau international nursing honor society. She delivers quality nursing care with a behavioral approach to individuals with autism and their parents, teaching them healthy lifestyles across their lifetime. Kevin J. Brothers, Ph.D. is the founding Executive Director of the Somerset Hills Learning Institute. Dr. Brothers earned his doctorate in Developmental and Child Psychology from the University of Kansas in 1999. Having studied with Donald M. Baer, Ph.D., Patricia J Krantz, Ph.D. and Lynn E. McClannahan, Ph.D., his research interests include issues in stimulus control, organizational behavior management, and incorporating digital technology in autism treatment. Dr. Brothersʼ articles have been published in the Journal of Applied Behavior Analysis and the Journal of Autism and Developmental Disabilities. He co-authored, with Dr. Anthony Cammilleri, the chapter: The Baer Necessities: Observation, Measurement, and Analysis, published in A Small Matter of Proof: The Legacy of Donald M. Baer in 2003. Previous positions include those held at the Princeton Child Development Institute (PCDI), Bancroft, Autism New Jersey, Lawrence Kansas Public School District, and as an educational consultant to public schools and families. Presenter Bios (Continued) Suzanne Buchanan, Psy.D., BCBA-D is the Clinical Director at Autism New Jersey, a licensed psychologist and Board Certified Behavior Analyst Doctoral (BCBA-D). She earned a doctorate in clinical psychology from Long Island University and has worked in the autism field for more than fifteen years. Dr. Buchanan provides Autism New Jersey with clinical leadership; supervises applied behavior analytic services for families and professionals; disseminates information regarding evidence-based intervention to parents, professionals, and the media; and advises public policy efforts from a clinical perspective. Her interests include family resilience, informed decision-making about autism intervention, and contributing to the development and implementation of state policies that impact the autism community and the professionals who support them. She currently serves as the Government Affairs Chair of the New Jersey Association for Behavior Analysis and is the co-author of Applied Behavior Analysis and Autism: An Introduction and other agency publications. Anthony Cammilleri, Ph.D., BCBA-D is a board-certified behavior analyst who holds a bachelors degree in psychology from Western New England College, a masters degree in behavior analysis from the University of North Texas, and a doctoral degree in developmental and child psychology from the University of Kansas. While completing his graduate studies, he served as the Principal Teacher of Century School in Lawrence, KS. Upon graduation, he served as a behavior analyst for the Somerset Hills Learning Institute. Tony currently serves as the Director and Jack B. Morris Chair of the Jane Justin School and the Child Study Center in Fort Worth, TX. Throughout his career, he has specialized in the design of individualized curriculum sequences, the use of measurement systems to assess the effectiveness of those sequences, and in the staff training required for the implementation of both. Tony is an active researcher in the field of developmental disabilities and has published his research in a variety of behavior analytic journals. Recently, he was honored by the Fort Worth Business Press as a member of the 2011 40 Under 40 class of community leaders. Tony is best known for educational leadership that promotes the virtues of citizenship, friendship, and scholarship -- the elements of an inclusive community whose members care for their world and one another, and enjoy a lifelong love of learning. Ruth M. DeBar, Ph.D., BCBA-D, is an Assistant Professor in the Department of Applied Behavior Analysis at Caldwell College and the Director of Outreach for the Caldwell College Center for Autism and Applied behavior Analysis. She has extensive experience assessing and developing interventions to address behavioral excesses and deficits of individuals diagnosed with Autism Spectrum Disorders (ASD). She also has provided intensive training to families and related professionals. Dr. DeBar earned her Masterʼs degree from Northeastern University via The New England Center for Children and completed her doctorate degree at The Ohio State University. She has published several peer-reviewed articles and has lead parent-professional workshops on various topics relevant to learners with ASD. Her current research interests include preference assessments, choice, social validity and reading instruction for learners diagnosed with an ASD. Michael Himle, Ph.D. earned his Ph.D. from the University of Wisconsin-Milwaukee in 2007. He is currently an Assistant Professor in the Department of Psychology at the University of Utah. He is an expert in behavioral approaches for understanding and treating behavioral disorders of childhood, with emphasis on anxiety disorders, obsessive-compulsive disorder and obsessive-compulsive spectrum disorders, especially Tourette Syndrome and Trichotillomania. He is active in researching environmental factors and behavioral processes involved in the onset and course of these conditions and translating this information into more effective treatments. He is also interested in dissemination strategies for behavior therapy. He has published more than 35 peer-reviewed publications and book chapters and has given more than 60 conference presentations and invited talks on Tourette Syndrome and related conditions. His research has received funding from the Tourette Syndrome Association and the Trichotillomania Learning Center. Presenter Bios (Continued) Laura Kenneally, Ed.D., BCBA is the Co-president of Advance, Inc., a private consulting agency offering behavioral and educational programming to school districts and families throughout New Jersey; and Executive Director of Partners in Learning, Inc. at Country Acres Private Preschool. She has presented workshops on topics in ABA including: Sleeping and Eating Issues, Sibling Support and Behavior Management. Gregory S. MacDuff, Ph.D., BCBA-D is Co-Executive Director of the Princeton Child Development Institute. He is Adjunct Professor in the Department of Applied Behavioral Sciences at the University of Kansas and the Department of Psychology at The College of New Jersey. He has authored articles and book chapters on incidental teaching, photographic activity schedules, staff training strategies, prompt- and prompt-fading procedures, behavioral intervention for adults with autism and intervention models in residential settings. He has lectured nationally and internationally, and has provided consultation and training to a variety of public and private programs.. Kathleen McCabe-Odri, Ed.D., BCBA-D is the Executive Director of Partners in Learning at Country Acres Private Preschool and Cherrywood Academy, inclusive preschools in Williamstown, and Clementon New Jersey; and Co-President of Advance, Inc., a private consulting agency serving students with autism and their families. She has presented workshops on topics in ABA including Curriculum Adaptations, Staff Training, Functional Analysis, and Inclusive Education for Children with Autism. NJABA 7th Annual Conference Registration For NJABA Members: The 1-day conference registration fee is $100 for advance registration ($125 at the door). For Non-Members: The 1-day conference registration fee is $150 ($200 at the door). If you are not a NJABA member but would like to become one and benefit from the reduced conference fee, please submit a membership form found at www.njaba.org with this registration form. Conference registration fee may be paid by check or credit card. If paying by credit card, visit www.njaba.org and click on the link for payment. You must still mail in your registration form if paying by credit card. If paying by check, please make check out to NJABA. Mail check payment with this registration form to: NJABA c/o CCSB, PO Box 159, Butler, NJ 07405 Title: ( ) Dr. ( ) Ms. ( ) Mrs. ( ) Mr. First & M.I. _______________________________ Last name: ________________________________________ Affiliation: _________________________________________________Position/Occupation: ___________________________________________ Address:________________________________________________________________________________________________________________ Phone #: _______________________________________ E-Mail (PLEASE PRINT CLEARLY): ___________________________________________ I am ( ) a NJABA member ( ) NOT a NJABA member but have applied to be one ( ) NOT a NJABA member and do not wish to apply Continuing Education - Indicate type of Continuing Education credits you need (if any) below. Instructions for obtaining Continuing Education credits will be provided at the NJABA conference. PAYMENT FOR CEUs WILL BE COLLECTED FROM YOU AT THE END OF THE CONFERENCE (DO NOT PAY FOR CEUs IN ADVANCE). NJDOE credits will be provided free of charge BACB credits cost $10 each (each workshop = 1.5 credits; keynote address = 3 credits) ASHA credits (CE cost will be provided by ASHA upon completion of conference) I will need CE credits for ( ) NJDOE ( ) BACB ( ) ASHA ( ) I do NOT need any CE credits Please indicate the workshops / symposia you would like to attend (one per time slot): Early Afternoon (12:45-2:15pm): ( ) #1 ( ) #2 ( ) #3 Late Afternoon (2:20-3:50pm): ( ) #4 ( ) #5 ( ) #6 Questions? Email conference@njaba.org Exhibitor Opportunity & Terms Exhibitor Cost: $175 (Includes Lunch) Exhibitor Hours: 11 AM - 12:45 PM Deadline for submission: February 28, 2012 Exhibitor Terms: • NJABA reserves the right to determine eligibility of any organization as an exhibitor. Applications for exhibit space will be reviewed and if accepted, the primary representative will be contacted within 15 business days of receipt of completed applications. • Vendors and agencies must set up and dismantle their own exhibits. Dismantling may not begin until 1:30pm. Exhibitors who break down early will not be invited back the following year. • The standard booth equipment as furnished by NJABA will consist of one 6 ́wide x 9 ́ long booth space with carpeting, 6 ́draped table and two chairs. Additional draping, furniture, accessories, signs, electrical outlets, A/V equipment, internet access, etc. are the financial responsibility of the exhibitor. An order form for A/V, electricity and internet will be sent to the primary representative one month prior to the conference. • No exhibitor shall sublet, assign or share any part of the space allocated to him/her without the written consent of NJABA. • Solicitations or demonstrations by exhibitors must be confined within the 6ʼ wide x 9 ́ long boundary of their respective spaces. Exhibits shall be constructed and arranged so that they do not obstruct the general view, or hide the exhibits of others. No signs, display units or chairs are permitted beyond the 6 ́wide x 9 ́ long booth space. • It is the responsibility of the exhibitor to see that all of his/her materials are delivered to and removed from the exhibit area by the specified deadlines. • NJABA reserves the right to restrict exhibits, which, because of noise, method of operation, materials or any other reason, become objectionable, and prohibit or evict any exhibit, which, in the opinion of NJABA, may detract from the general character of the conference as a whole. In the event of such restriction or eviction, NJABA is not liable for any refund or other exhibit expenses. Cancellation Policy: Exhibit fees paid to NJABA will be refunded if written notice of cancellation is received prior to February 28, 2012. Cancellation after February 28, 2012 obligates the exhibitor to pay full rental costs. Liability: Exhibitors shall assume full responsibility for the protection of their property. It is recommended that exhibitors take precautionary measures of their own, such as the securing of small or easily portable articles of value and the removal of them to a place for safe-keeping after exhibit hours. Neither NJABA nor The Bridgewater Manor maintains insurance coverage for the exhibitorʼs property and it is the exhibitorʼs responsibility to obtain such insurance. Exhibitor Application The conference program exhibitor guide will be based on the following information. Only list organizational information. If you must list personal information (home address, cell phone number, etc.) clearly note if you do not want this information published. Deadline for submission: February 28, 2012 (Refunds will not be considered for any application received after the submission deadline.) Exhibitor Cost: $175 Exhibitor Information Organization name:________________________________________________________________________________ Type of service or product:__________________________________________________________________________ Attending representative (1):_________________________________________________________________________ Attending representative (2):_________________________________________________________________________ Organization Street address:_________________________________________________________________________ City:_____________________________________ State:_____________ Zip:______________________ Telephone:__________________________________ Fax:_____________________________________ Attending representative e-mail:______________________________________________________ Payment Information: Check # ______________ Money Order # ______________ Credit card: ______Visa _____MasterCard _____American Express _____ Discover Card number:________________________________________________ Name on card:_______________________________________ Expiration Date ____________________________ Signature (required for credit card)____________________________________________________ Agreement to Terms: A duly authorized agent of the exhibitor must sign the application for exhibit space. Such signature will reflect full reading and comprehension of all specified terms. The undersigned agrees to the conditions, rules and regulations set forth in the NJABA Exhibit Terms: _______________________________________________________________________ Printed name of primary representative _______________________________________________________________________ Signature Date Mail this page with form of payment (credit card, money order, or check made out to NJABA) to: NJABA c/o CCSB, PO Box 159, Butler, NJ 07405 Questions? Email conference@njaba.org Advertising Opportunity & Application Please submit all ads via email by the indicated deadlines to Tara Ferrigno at info@somerset-hills.org . For more information, please call Tara at 908-719-6400. Ads must be sent as a photo-ready file. Deadline for submission: March 16, 2012 (Refunds will not be considered for any application received after the submission deadline.) Program Advertising: A black and white, 8.5” x 11” sheet advertisement will be inserted into the Conference Program Portfolio which will be distributed to all conference attendees to be used as a resource guide throughout the year. Promote your organization or company, advertise a job opening, or endorse your product or service. Show your support for NJABA! Advertising Cost: $100 (Full Page ) Advertiser Information Organization name:________________________________________________________________________________ Contact Person:___________________________________________________________________________________ Street address:____________________________________________________________________________________ City:_____________________________________ State:_____________ Zip:______________________ Telephone:__________________________________ Fax:_____________________________________ Email:_______________________________________________________________________________ Payment Information: Check # ______________ Money Order # ______________ Credit card: ______Visa _____MasterCard _____American Express _____ Discover Card number:________________________________________________ Name on card:_______________________________________ Expiration Date ____________________________ Signature (required for credit card)____________________________________________________ Mail this page with form of payment (credit card, money order, or check made out to NJABA) to: NJABA c/o CCSB, PO Box 159, Butler, NJ 07405 Questions? Email conference@njaba.org