1. Name: 2. Date of Birth: 3. Social Security Number: 4. Email Address: 5. Home Street Address: 6. City: 7. State: 8. Zip Code: 9. Country: 10. Home Telephone Number: 11. Alternate Telephone Number: 12. Fax Number: 13. Gender: Male Female 14. Age: Under 18 18-24 25-34 35-44 45-54 55-63 over 64 15. Resident of: Urban Community Rural Community 16. Ethnicity Caucasian (non-Hispanic) Hispanic African-American (non-Hispanic) Native American Pacific Islander Caribbean Islander Other Student Professional Information 17. I am a: Service Provider Educator Vendor Individual with disability Other More than one of above 18. Which one of these best describes your profession? OT PT Speech Audiology Psychology Education RN Rehab Specialist Engineer Social Worker Computer Specialist Home Eval Specialist Recreation Specialist Music Specialist Advocate Vision Specialist Physician Other (what?) 19. Education/Degree:
2. Date of Birth:
3. Social Security Number:
5. Home Street Address:
6. City:
7. State:
8. Zip Code:
9. Country:
10. Home Telephone Number:
11. Alternate Telephone Number:
12. Fax Number:
13. Gender:
Male Female
14. Age:
Under 18 18-24 25-34 35-44 45-54 55-63 over 64
15. Resident of:
Urban Community Rural Community
16. Ethnicity
Caucasian (non-Hispanic) Hispanic African-American (non-Hispanic) Native American Pacific Islander Caribbean Islander Other
Student Professional Information
17. I am a:
Service Provider Educator Vendor Individual with disability Other More than one of above
18. Which one of these best describes your profession?
OT PT Speech Audiology Psychology Education RN Rehab Specialist Engineer Social Worker Computer Specialist Home Eval Specialist Recreation Specialist Music Specialist Advocate Vision Specialist Physician Other (what?)
19. Education/Degree:
Less than High School High School Associate Bachelor Master Doctorate Post-Doctorate
20. Professional License Number: 21. Type of Certification: 22. Employed:
20. Professional License Number:
21. Type of Certification:
22. Employed:
Not Employed Student Part Time Employment Full Time Employment Retired Per Diem Other (what)
23. Title: 24. Organization:
23. Title:
24. Organization:
25. Organization/Work Address: 26. City:
25. Organization/Work Address:
26. City:
27. State:
28. Work Telephone:
29. Work Fax Number:
Assistive Technology Background
Disability Involvement (select all applicable): I work with Individuals with Disabilities I have a Family Member with a Disability I have a Disability Both a Family Member and I have a Disability Other (what?) Years of Assistive Technology related work experience? How did you learn about the course?
Disability Involvement (select all applicable):
I work with Individuals with Disabilities I have a Family Member with a Disability I have a Disability Both a Family Member and I have a Disability Other (what?)
Years of Assistive Technology related work experience? How did you learn about the course?
Audio/Visual Compatibility Questions
Does your computer have a CD drive: Yes No Do you have access to a VCR? Yes No
Does your computer have a CD drive:
Yes No
Do you have access to a VCR?
Payment Selection:
For University of Miami Credit (3 credit hours): $1650 for all 30 presentations. Please contact Cary Vega at (305) 243-4466 for more information prior to sending registration form. For Continuing Education: Tuition for the 30 presentation course is $795. Tuition for Individual Sections of the course is (check all that apply):
For University of Miami Credit (3 credit hours): $1650 for all 30 presentations. Please contact Cary Vega at (305) 243-4466 for more information prior to sending registration form. For Continuing Education:
Tuition for the 30 presentation course is $795. Tuition for Individual Sections of the course is (check all that apply):
Discounts are available to participants who are residents of Alabama, Georgia, Florida, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee. Please contact Michelle Schladant at (305) 243-4466 for information related to discounts prior to sending registration form.
Please make all payments payable to: University of Miami MCCD: Pediatrics/A.T. Conference
Please select your choice of payment and mail form with payment attached. (See mailing address below.)
Check #: Institution PO #: Credit Card: AmEx Card Number Visa Card Number MC Card Number Authorizing Signature ________________________ Expiration Date (Original Signature Please) Mail to: University of Miami Mailman Center for Child Development 1601 NW 12 Avenue, Room 4021 Miami, FL 33136
Check #:
Institution PO #:
Credit Card:
AmEx Card Number Visa Card Number MC Card Number Authorizing Signature ________________________ Expiration Date (Original Signature Please)
AmEx Card Number
Visa Card Number
MC Card Number
Authorizing Signature ________________________ Expiration Date (Original Signature Please)
Mail to:
University of Miami Mailman Center for Child Development 1601 NW 12 Avenue, Room 4021 Miami, FL 33136
© 2004 University of Miami, Department of Pediatrics. All rights reserved. [Medical Campus] [Coral Gables Campus]