1. Name:

2. Date of Birth: 

3. Email Address:

4. Home Street Address:

5. City:

6. State:

7. Zip Code:

8. Country:

9. Home Telephone Number:

10. Alternate Telephone Number:

11. Fax Number:

12. Gender:

Male
Female

13. Age:

Under 18
18-24
25-34
35-44
45-54
55-63
over 64

14. Resident of:

Urban Community
Rural Community

15. Ethnicity

Caucasian (non-Hispanic)
Hispanic
African-American (non-Hispanic)
Native American
Pacific Islander
Caribbean Islander
Other

Student/Professional Information

16. I am a (please check all that apply):

Service Provider
Educator
Vendor
Individual with disability
Other

17. 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?)

18. Education/Degree:

Less than High School
High School
Associate
Bachelor
Master
Doctorate
Post-Doctorate

19. Professional License Number:

20. Type of Certification:

21. Employment:

Not Employed
Student
Part Time Employment
Full Time Employment
Retired
Per Diem
Other (what)

22. Title: 

23. Organization:

24. Organization/Work Address:   

25. City:

26. State:

27. Work Telephone:

28. Work Fax Number:

 
Assistive Technology Background

Disability Involvement (select all that apply):

I work with Individuals with Disabilities
I have a Family Member with a Disability
I have a Disability
Other (what?)

How many years of Assistive Technology related work experience do you have?

How did you learn about this AT course?

Course Participation Options:

OPTION ONE- 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 payment.

OPTION TWO- Continuing Education:

Express Course Tuition- You will have access to work on the entire course withoput the interruptions of registering for each section. Cost: $795.00 (an $80 savings)

Tuition for Individual Sections- Check all of the desired sections:

OPTION THREE- CEU Contact Hours:

Physical Therapy Professionals, that are FLORIDA licensed, can receive C.E.U. Contact hours. Fee $20.00 per certificate of completion. Please contact Wanda Castro at (305) 243-4466 or email at wcastro@med.miami.edu with any questions about contact hours.

Payment Selection Options: If paying with check or purchase order, please mail your payment with a copy of the registration form to our mailing address listed below.

Check #:

Institution PO #:

Credit Card (Please print this form and then handwrite in your credit card information in the space provided below. Information should be carefully printed and then mailed to the address below. There is no way to add your information to this form online for security purposes when submitting this form.)

Visa Card Number: ____________________________________

Master Card Number: __________________________________

American Express Card Number: _________________________

Expiration Date: _______________

Authorizing Signature: __________________________________

Please make all payments payable to: University of Miami MCCD: Pediatrics/A.T. Conference

Payments and this form should be mailed to:

University of Miami

Mailman Center for Child Development

1601 NW 12 Avenue, Room 4021
Miami, FL 33136

Please print a copy and mail it to the address above with your payment.