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   Glazebrook & Associates                Today's Date ___________________
   30 Rohde Ave.
   St. Augustine, FL 32084

   Voice 773.525.5977      
   Fax   904.825.0565


   NOTE: We NEVER sell or give away PERSONAL information given to us! 


        I wish to receive my FREE copy of "Star Parents" (a $11 value)! 
   Enclosed is nine dollars ($9) to cover shipping and handling. 

   Name __________________________________________________________________
 
 
   Title _________________________________________________________________


   School or Program _____________________________________________________


   email Address _________________________________________________________


   Address (No P.O. Boxes) _______________________________________________


   Address Line two _____________________________________________________


   City: ______________________________ State: ______ Zip: _______________


   Phone: (        ) _________________ Fax: (        ) ___________________




   Does your school/program work with parents (Yes/No)?  _________


   If Yes, how many over a calendar-year's time? _________________




   Does your school/program purchase parenting related materials? ______


   If Yes, but YOU do not make the decision on which parenting materials
   are bought, please provide on the next page the information of the person
   who is the decision maker so we can also ship them a free copy of 
   "STAR PARENTS" along with our catalog.  Thanks.
 


   Name __________________________________________________________________
 
  
   Title _________________________________________________________________


   email Address _________________________________________________________


   Address (No P.O. Boxes) _______________________________________________


   Address Line two _______________________________________________________


   City: ______________________________ State: ______ Zip: _______________