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Moe the Mouse® Request Form

 


Moe the Mouse® Speech and Language Development Program

A Program of the BC Aboriginal Child Care Society
Developed by Anne Gardner, SLP & Margaret Chesterman, SLP for ACCS

 

ORDER FORM
If you would like to attend a Moe the Mouse® workshop, host a workshop for your community, or borrow or purchase a Moe the Mouse® Curriculum Box, please fill out this form:
* Name of Centre, Agency, School, etc.
For schools, please include School District #
Nation: (if applicable)
Contact Person:
* First Name
* Last Name
Title (if applicable)
* Phone: (please include area code)
Fax: (please include area code)
* E-mail:
Mailing address:
* Street or PO Box
* City
* Province
* Postal Code
Physical address: (for courier deliveries)
Street
City
Province
Postal Code
We cannot courier to PO Box addresses; if you provide a PO Box only, your delivery will be mailed. For some places in BC, we cannot arrange door-to-door delivery by courier, so we will mail to those places.
Billing address: (if different from mailing address)
Street
City
Province
Postal Code
If the contact person for your invoice/billing is different from the main contact person for this order, please provide name, phone, fax and e-mail for billing contact person. If you want the invoice sent to the main contact person for this order, leave this section blank.
Billing Contact
First Name
Last Name
Title (if applicable)
Phone:
(please include area code)
Fax:
(please include area code)
E-mail:
What do you want to order or find out?
I want to purchase the following items:
(An invoice will be sent to you; after payment, we will deliver your items)
  Price Quantity
Moe the Mouse® Curriculum Box $500*
Felt Story Version of the Moe the Mouse® Curriculum Box $200*
Moe the Mouse®
Felt Story
 $70** 
Check all that apply I want information about training workshops: (Someone will call or e-mail you with more information)
  I want to attend a Moe the Mouse® workshop

  I want to find out more about hosting a Moe the Mouse® workshop in my community
  I have questions or want some more information about Moe the Mouse® workshops, and would like to speak to someone by phone
   



You can also send your completed Order Form to Pepper Brewster,
Librarian for ACCS, by e-mail, fax or snail mail:

E-mail: library@acc-society.bc.ca
Fax: 604.913.9129 Attention: Pepper Brewster
Mail: BC Aboriginal Child Care Society – Moe the Mouse®
102 – 100 Park Royal South
West Vancouver, BC V7T 1A2