"The Brain and Irlen Syndrome" - A three (3) credit graduate course for those who have already taken the
two day Irlen Screener Training

Name: __________________________________________________________________

Address: ________________________________________________________________

City: ____________________________________ State: ________ Zip Code: _________

Email: __________________________________________________________________

Phone(Home):_____________________ Phone(work or cell):_______________________

Check off and fill in those items which apply to you.
I am a:
___Irlen Clinic Director ___Irlen Diagnostician ___Certified Irlen Screener

I was trained (date): ______________ Location/city & state: __________________

By (Name of Trainer): __________________________________

I practice at (location): __________________________________________________

PAYMENT INFORMATION
COST: $395 made out to Irlen Center Boston.

*Do not send your forms to Cambridge College, instead mail, fax or email them to the attention of
Georgianna Saba at the Irlen Center Boston.*

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You may pay with Master Card, Visa, or personal check

Credit Card Type(circle one): Master Card or Visa Expiration Date(mm/yy): ________

Credit Card #________/_________/________/_________ Payment Amount: $395.00

Name on Card: _______________________________________________________

Signature:_____________________________________

Contact: Georgianna Saba, Irlen Center Boston, 25A Mabelle Ave, Medford, MA 02155
781-396-3321, (Fax) 781-396-3010 email: Irlenboston@aol.com