Registration TAP 1.3 Basic Elements of Structured Teaching for Parents/Guardians MAY 11, 2010 Name:
Gender (M/F):
Home Address: State:
Date of Birth (mm/dd/yy): City:
Zip:
Home Phone (w/area code):
Cell Phone (w/area code):
Place of Employment: Address: State:
City: Zip:
Work Phone (w/area code):
Personal E-mail:
Work E-mail:
Age of Child(ren) with autism:
School(s) attending:
Type of Classroom:
Name of School District:
Home Program:
Private Therapies:
Will you require any special assistance or accommodations during training?
Fax Number (w/area code):
If yes, please specify:
How did you learn about this training program? Please list your previous TEACCH/TAP trainings (including dates and locations):
Payment Options: - Credit Card (Please check): Visa _________ MasterCard __________ Name on Card: ________________________ Card # ____________________________ Expiration date: ______________ - Check this line if you are enclosing a check (payable to HAVE DREAMS): ______________________ - Check this line if you are paying by Purchase Order: # _______________________________
REGISTER NOW! Admission is on a first-come, first-served basis (limit 50 participants) Cost $ 100 (Lunch included) To register by e-mail, attach this registration (please indicate payment method) and email to:
[email protected] To register by fax, return this registration (please indicate payment method) to 847-685-0257, Attn: Lydia To register by mail, return this registration with payment (check payable to HAVE DREAMS, credit card or P.O. info) to: HAVE Dreams 515 Busse Highway, Suite 150 Park Ridge, 60068 Attn: Lydia Wissijg Phone 847- 685-0250 (Ext 111)