Online Class Registration Form

"Fundamentals of Interdisciplinary Collaboration:
Providing Care to Children with Special Needs and Their Families"

Student Information

 

1. First Name:
    Last Name:

 

2. E-mail Address:

 

3. Profession: (Check all that apply.)

Audiology
Advocate
Child Care Director
Child Care Staff
Dentistry
Early Interventionist
Education
Regular Education Teacher
Nutrition
Occupational Therapist
Physical Therapy
Physician, What type: 
Psychology
Registered Nurse
Social Worker
Speech and Language Pathology
Special Education Teacher
Other: 

 

4. Education/Degree:

Less than High School
High School
Associate
Bachelor
Master
Doctorate
Medical Doctorate (M.D.)
Post-Doctorate

 

5. Day Telephone Number:

 

6. Clinical Supervisor's Name:

 

Signature: ________________________________                                   Date: _______________

 

By signing this form you signify your acceptance
of the disclaimer displayed at the bottom of this page.

(After printing the disclaimer may appear on the second page)

 

 

Please, print this form and mail to:

 

Mailman Center for Child Development

1601 NW 12th Avenue

Locator Code: D-820 ; Room# 4023

Miami, FL. 33136

Attn: Benjamin or Wanda

 

DISCLAIMER:

Department of Pediatrics, Mailman Center for Child Development
at the University of Miami School of Medicine Disclaimer:
The pages and links included herein are provided for educational purposes only and do no not necessarily represent recommendation by the University of Miami or the Department of Pediatrics, Mailman Center who have collaborated to produce this course. Neither the University of Miami nor the Department of Pediatrics, Mailman Center have any financial interest or other relationship with the manufacturers of any commercial products and/or suppliers of commercial services discussed in any educational presentation or suggested links. The University of Miami makes no warranties whatsoever, express or implied, as to the information and links contained herein or as to their accuracy, completeness or usefulness related to issues discussed or included on such pages, discussion boards/chat rooms, or links. The University assumes no liability for the contents of these pages, discussion boards/chat rooms, and/or links, and each user accessing these pages agrees to hold harmless and release the University of Miami from any and all claims arising from the contents of these pages, discussion boards/chat rooms, and/or links. Various clipart, video, and image collections appearing on this site are for viewing purposes only. Any reproduction may be prohibited under confidentiality and/or federal/state copyright/trade secret laws.