ACC Continuing Education Registration Form Date: ______
FOR ASL TEACHER CERTIFICATION TRAINING - 2005-2006
Last Name First MI Date of Birth Social Security Number
Mailing Address / City / State / Zip CodeHome Phone / Work Phone / Email Address / In District/Out of District
Name of Course / Start Date /
Course Prefix
/ Course # / Synonym # / Section # /Campus
/ Tuition / Amount Paid / Date Paid / Payment MethodIn District / Out of District
ASL registration fee
American Sign Language /
4/22/05
6/20/05
/EDTC
SLNG
/5050
1045
/79111
78531 /340
401
/HBC
RGC
/$40
$600
/$40
$750
/ / /Total Tuition and Fees
Please Check One: (for State Reporting Purposes)
Ethnicity/Race: Gender:
Hispanic/Latino Black/African American Female
Asian American Indian/Alaskan Native Male
Native Hawaiian/Pacific Islander White
Other
Please read the reverse side/page 2 for important information regarding Bacterial Meningitis.
Complete the area below if using a credit card to register by Fax (512) 223-7030 or by mail. American Express is no longer accepted.
Circle one: VISA MasterCard Discover Expiration Date: ______Amount charged $ ______
Name on card: ______Signature: ______
££££££££££££££££
Resources for Immunizations
Clinic Location Phone
PRO MED: 3601 S. Lamar, Austin (512) 447-9661
13831 N. Hwy 183, Austin (512) 250-0424
2000 W. Anderson, Austin (512) 459-4367
Austin Diagnostic Clinic – (Travel Clinic Only) Appointment Required.
12221 N. Mopac, Austin (512) 901-4486
Williamson County Locations – Appointment required at all the following locations:
Cedar Park Clinic 350 Discovery Blvd Ste 102, Cedar Park (512) 260- 4240
ACC ID and Verification from HS Program Required.
Monday: 8:00am – 11:00 & 1:00pm – 2:00pm
Wednesday (No TB tests): 8:00am – 11:00am & 1:00pm – 2:00pm
Georgetown Clinic 100 3rd St, Georgetown (512) 930- 4386
ACC ID and Verification from HS Program Required.
Wednesday: 8:00am – 1:00 & 1:00pm – 3:00pm
Thursday (No TB Tests): 8:00 am – 11:00 & 1:00 pm – 2:00pm
Round Rock Clinic 211 Commerce Cove, Round Rock (512) 248- 3257
ACC ID and Verification from HS Program Required.
Thursday: 8:00am – 11:00am & 1:00pm – 2:00pm
Taylor Clinic 115 West 6th Street, Taylor (512) 238- 2121
ACC ID and Verification from HS Program Required.
Tuesday: 8:00am – 11:00am & 1:00pm – 3:00pm
TB CLINIC: 15 Waller St., Austin (512) 972-5460
(Rebecca Baines Johnson Building, 1st Floor)
Friday: 1:00 pm – 3:00 pm Test Administered
Monday: 11:00 am – 12:00 pm Test Read
TB w/exam / TB w/o exam / Varicella / Varicella Titer / Hepatitis B / Hepatitis B TiterPRO MED / $12 / $24 / $84 x 2 = $168 / $73 / $77 x 3 = $231 / $47
ADC / $10 / $30 / $88 x 2 = $176 / $83 / $84 x 3 = $252 / $35
WCCHD / $20 / $30 x 3 = $90
TB CLINIC / $15
Important Information about Bacterial Meningitis
This information is being provided to all new college students in the state of Texas. Bacterial Meningitis is a serious, potentially deadly disease that can progress extremely fast – so take utmost caution. It is an inflammation of the membranes that surround the brain and spinal cord. The bacteria that cause meningitis can also infect the blood. This disease strikes about 3,000 Americans each year, including 100-125 on college campuses, leading to 5-15 deaths among college students every year. There is a treatment, but those who survive may develop severe health problems or disabilities.
What are the SYMPTONS?
High fever, lethargy, nausea, rash or purple patches on skin, severe headache, seizures, light sensitivity, vomiting, confusion and sleepiness, stiff neck.
There may be a rash of tiny, red-purple spots caused by bleeding under the skin. These can occur anywhere on the body. The more symptoms, the higher the risk -- when these symptoms appear seek immediate medical attention.
How is bacterial meningitis DIAGNOSED?
Diagnosis is made by a medical provider and is usually based on a combination of clinical symptoms and laboratory results from spinal fluid and blood tests. Early diagnosis and treatment can greatly improve the likelihood of recovery.
How is the disease TRANSMITTED?
The disease is transmitted when people exchange saliva (such as by kissing, or by sharing drinking containers, utensils, cigarettes, toothbrushes, etc.) or come in contact with respiratory or throat secretions.
How do you increase your RISK of getting bacterial meningitis?
· Exposure to saliva by sharing cigarettes, bottles, eating utensils, food, kissing, etc.
· Living in close conditions (such as sharing a room/suite in a dorm or group home).
What are the possible CONSEQUENCES of the disease?
Death (in 8 to 24 hours from perfectly well to dead), learning disability, permanent brain damage, hearing loss, blindness, kidney failure, gangrene, limb damage (fingers, toes, arms, legs) that requires amputation, coma, convulsions.
Can the disease be TREATED?
Antibiotic treatment, if received early, can save lives and chances of recovery are increased. However, permanent disability or death can still occur. Vaccinations are available and should be considered for: those living in close quarters and/or college students 25 years old or younger. Vaccinations are effective against 4 of the 5 most common bacterial types that cause 70% of the disease in the U.S. (but does not protect against all types of meningitis). Vaccinations take 7-10 days to become effective, with protection lasting 3-5 years. The cost of vaccine varies so check with your health care provider. Vaccination is very safe – most common side effects are redness and minor pain at injection site for up to two days. Vaccination is available through your local physician.
How can I find out more INFORMATION?
Contact your health care provider and/or your local or regional TX Dept of Health.
Contact Websites: www.dshs.state.tx.us ● www.thecb.state.tx.us ● www.cdc.gov/ncidod/dbmd/diseaseinfo ● www.acha.org ● www.musa.org