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CVI Training Registration - 12.14.18
REGISTRATION FORM - Dr. Christine Roman-Lantzy - CVI Workshop, 12/14/18
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1.
What is your first name?
(Required.)
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2.
What is your last name?
(Required.)
3.
What is your email address?
4.
What is your mailing address?
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5.
What is the best way to contact you? List Phone Number in Comment Field.
(Required.)
Voice/Phone
Text Message
Best Phone Number:
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6.
Please list your employer (if school, name district as well):
(Required.)
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7.
Please list your position title:
(Required.)
8.
In regards to this training, do you have a particular child in mind who has CVI?
Yes
No
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9.
Do you have special dietary needs? If yes, please describe (If NO, put N/A):
(Required.)
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10.
Do you have any special communication needs? If yes, please select all that apply (If NO, put N/A) NOTE: This request MUST be made by November 29, 2018:
(Required.)
N/A
ASL Interpreter
Braille
Large Print
Electronic Handouts
Other (please specify)
Please click on the word "Done" to submit your registration form.
We will email a confirmation of registration to you shortly.