CURRICULUM ORDER FORM

Helping Mothers and Children Survive

Abuse Together Curriculum:

Partner Rate:  $75.00

Non Partner Rate:  $100.00

Quantity Requested  FORMCHECKBOX                    Cost: $___________

Lunch Group Curriculum:

Partner Rate:  $35.00

Non Partner Rate:  $45.00

Quantity Requested  FORMCHECKBOX                    Cost: $____________

Breaking Down Walls Curriculum:

(Adolescent Program)

Partner Rate:  $30.00

Non Partner Rate:  $40.00

Quantity Requested  FORMCHECKBOX                    Cost: $____________

                     TOTAL COST:  $___________

AGENCY NAME AND ADDRESS:

_________________________________

_________________________________

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Please Note: Shipping and Handling fees will be applied to total (cost)

if purchased after conference date.

****CASH OR CHEQUES ONLY TODAY****

(Please make cheques payable to: The HEAL Network)