Name: ______________________________________________________________________________________

Phone Number(s): ____________________________________________________________________________

Home Address: ______________________________________________________________________________

E-mail: ____________________________________________

Check all that Apply:

Professional ____        Parent of Child with Disability _____ 

If Professional, what is your specialization (e.g., teacher, speech language pathologist)? ____________________________ 

Training Week Preferences: (write 1 or 2 to indicate) 

____  June 9-13       ____ June 16-20
 

Briefly Describe Your Experience with Children with Autism:
 
 
 
 
 
 
 
 
 

Briefly Describe Your Goals for the Training: