Statewide Training in Autism

Statewide Training in Autism

Trainer Application Form

The Mississippi Department of Mental Health, Boswell Regional Center is sponsoring an Autism Statewide Training Initiative designed to build capacity in the state to provide evidence-based, life-span services and supports to individuals with autism spectrum disorder (ASD) and their families.

The initiative employs a trainer of trainersmodel to provide free Foundations Training in Autism Spectrum Disorder across the state. We are looking for trainers to participate in the initiative. A good candidate is someone with experience in working and/or living with autism spectrum disorder, who is comfortable with public speakingand who has a passion and enthusiasm for supporting individuals with ASD. If you would like to be considered as a trainer, please complete the following application and submit it to Lisa Bryant at or Boswell Regional Center, 1049 Simpson Highway 149, Magee, MS 39111. For questions, contact Lisa at 601-867-5000 ext. 75117

Name:

Mailing Address:

Telephone number

Email

Give a brief description of your credentials related to ASD. Indicate where you work and your profession or discipline including whether or not you are the family member or an individual with ASD.

Indicate the number of years in your discipline and/or the age of your child(ren) w/ASD and/or your age if an individual w/ASD.

How do you stay current on best practices and approaches used with individuals with ASD? (Websites, professional or parent organizations (state, local, national), literature)

Check ASD areas/topics in which you have provided professional development, the target audiences and the duration/length of the presentation per topic. Check all that apply.

ASD TOPICS / AUDIENCES / DURATION
[] Characteristics of ASD
[] Early Intervention
[] School-age population
[] Adult population
[] Behavior
[] Communication
[] Social Skills
[] Family issues and Support
[] Transition
[] TeamingCollaboration
[] Sensory Processing
[] Evidence-based practices (EBPs) Please specify which ones:

Other autism topics:
Other non-autism topics:
/ [] Professionals [] Paras [] Families
[] Professionals [] Paras [] Families
[] Professionals [] Paras [] Families
[] Professionals [] Paras [] Families
[] Professionals [] Paras [] Families
[] Professionals [] Paras [] Families
[] Professionals [] Paras [] Families
[] Professionals [] Paras [] Families
[] Professionals [] Paras [] Families
[] Professionals [] Paras [] Families
[] Professionals [] Paras [] Families
[] Professionals [] Paras [] Families
[] Professionals [] Paras [] Families
[] Professionals [] Paras [] Families / [] 1-2 hrs [] ½ day [] 1day [] 2 days
[] 1-2 hrs [] ½ day [] 1day [] 2 days
[] 1-2 hrs [] ½ day [] 1day [] 2 days
[] 1-2 hrs [] ½ day [] 1day [] 2 days
[] 1-2 hrs [] ½ day [] 1day [] 2 days
[] 1-2 hrs [] ½ day [] 1day [] 2 days
[] 1-2 hrs [] ½ day [] 1day [] 2 days
[] 1-2 hrs [] ½ day [] 1day [] 2 days
[] 1-2 hrs [] ½ day [] 1day [] 2 days
[] 1-2 hrs [] ½ day [] 1day [] 2 days
[] 1-2 hrs [] ½ day [] 1day [] 2 days
[] 1-2 hrs [] ½ day [] 1day [] 2 days
[] 1-2 hrs [] ½ day [] 1day [] 2 days
[] 1-2 hrs [] ½ day [] 1day [] 2 days

What professional development delivery methodologies have you utilized? Check all that apply.

[] Face-to-face workshop
[] On-line
[] On-site technical assistance
[] Model site visit
[] Work group
[]Other ______

Please list 3-5 participantsfrom your training(s)/presentation(s)whowould be willing to serve as a reference for you.

Name / Phone / Email

Mississippi Statewide Autism Training Initiative, Trainer ApplicationPage 1