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Order Form
Please note:
A
printable (PDF) version
of this form is available.
Breaking the Silence: Giving Voice to Persons Living with Dementia
Quantity
Price
Total
1 DVD Format
x
$45.00
=
$
1 VHS Format
x
$40.00
=
$
Special Offer: with purchase of
Dementia Care Education Series
CD-ROM or
I'm Still Here
DVD
x
$25.00
=
$
Dementia Care Education Series
Quantity
Price
Total
1 CD-ROM
x
$55.95
=
$
1 CD-ROM and Facilitator Guide
x
$95.95
=
$
3 CD-ROMs and Facilitator Guide
x
$149.95
=
$
Each additional Facilitator Guide
x
$35.00
=
$
I'm Still Here
Quantity
Price
Total
1 DVD
x
$55.95
=
$
1 DVD for persons with dementia or partners in care
x
$40.00
=
$
1 DVD and Teaching-Learning Guide
x
$85.95
=
$
1 DVD and 3 Teaching-Learning Guides
x
$135.95
=
$
Each additional Teaching-Learning Guides
x
$25.00
=
$
A Changing Melody
Quantity
Price
Total
Taking Control of our Lives (2005) 2 DVD-set
x
$25.00
=
$
A Changing Melody Toolkit
x
$65.95
=
$
Managing and Accommodating Responsive Behaviours in Dementia Care
(no GST or additional shipping charges need to be applied for this item)
Quantity
Price
Total
1 DVD format and Resource Guide
x
$20.00
=
$
1 VHS format and Resource Guide
x
$20.00
=
$
Sub-total
$
(a)
GST 5%
(GST Tax Reg: R119260685)
$
(b)
Shipping/Handling Costs by Destination
Total Order
Within
Canada
U.S.
(by air)
Int'l
(by air)
1 to 5 CD/DVD/VHS Tapes
$2.00
$5.00
$8.00
1 to 5 CD/DVD/VHS Tapes and 1 Guide
$8.00
$13.00
$28.00
1 to 5 CD/DVD/VHS Tapes & upto 4 Guides
$10.00
$18.00
$44.00
Larger Orders (eg, 10 DVDs & 10 Guides)
$20.00
$30.00
$55.00
* For bulk orders, please contact MAREP for shipping and handling costs
Shipping/Handling Costs
(calculated from table above)
$
(c)
Total Order (add a+b+c)=
$
Method of Payment
*
If using credit card, charges will appear on your statement as "UW Cashier's Office."
Cheque (Canadian Funds) Payable to "University of Waterloo"
Visa
Mastercard
Name on Card:
Card Number:
Expiry Date:
Total Remittance:
*
$
Mailing Information
Name:
*
Address:
*
City:
*
Province/State:
*
Country:
*
Postal Code:
*
Phone:
(
) -
Fax:
(
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E-mail:
*
Indicates required field.
If paying by cheque, mail to:
Murray Alzheimer Research and Education Program
University of Waterloo
LHI 1629
Waterloo, ON,
Canada N2L 3G1
Phone: 519-888-4567 x35040
Fax: 519-746-6776
