Small Lessons. Big Difference. Survey

Small Lessons. Big Difference.
Social skills activities to model, shape and reinforce social understanding.

A free interactive workshop for parents to help your child develop the skills needed to form successful relationships with tearchers, friends and family.

March 5, 2010
10:00 - 12:00
Dunn Loring Center
Entrance 2, Room 1
2334 Gallows Road
Dunn Loring, Virginia 22027

*
1. Name

Name

*
2. phone number

phone number

*
3. e-mail address

e-mail address

4. How did you hear about this workshop?

	Please Check answer
PRC web site	*How did you hear about this workshop? PRC web site Please Check answer
PRC Newsletter	PRC Newsletter Please Check answer
Keep In Touch Email	Keep In Touch Email Please Check answer
Flyer sent home	Flyer sent home Please Check answer
Parent group	Parent group Please Check answer
Listserv	Listserv Please Check answer

Other (please specify)

5. Accommodations are available for workshops. Please let us know
two weeks in advance if you need any of these services or contact
the PRC at 703-204-3941.

	Yes	No
Do you need accommodations to attend this workshop?	*Accommodations are available for workshops. Please let us know two weeks in advance if you need any of these services or contact the PRC at 703-204-3941. Do you need accommodations to attend this workshop? Yes	Do you need accommodations to attend this workshop? No

Please provide a short description of required needs?

6. Interpreters are available for workshops. Please let us know
two weeks in advance if you need any of these services or contact
the PRC at 703-204-3941.

	Yes	No
Do you need an interpreter to attend this workshop?	*Interpreters are available for workshops. Please let us know two weeks in advance if you need any of these services or contact the PRC at 703-204-3941. Do you need an interpreter to attend this workshop? Yes	Do you need an interpreter to attend this workshop? No

Please provide a short description of required needs?

7. Additional Participants: If you are registering additional
participants,please indicate the total number in your group.

Additional Participants: If you are registering additional
participants,please indicate the total number in your group.
2

Small Lessons. Big Difference.

1. Small Lessons. Big Difference.

*1. Name

*2. phone number

*3. e-mail address