Florida Department of Education Center for Autism and Related Disabilities

FREE Regional Workshop inMiami-DadeCounty!

October 8, 2005

9:00 am – 3:00 pm

UM CARD

5665 Ponce de Leon Blvd

Coral Gables, FL 33146

Directions to Training Location:

From North, take I-95 South and follow US-1 south bound until S. Alhambra Circle. Make a right at S. Alhambra Circle. Drive into the Ponce de Leon Parking Garage, 5th Floor.

From South, take US-1 North and make a left when you reach S. Alhambra Circle. Drive into the Ponce de Leon Parking Garage, 5th Floor.

For more information contact: Jose Antonio Muñoz at UM CARD (305) 284-3722

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Registration Information

SPACE IS LIMITED!

REGISTRATION IS MANDATORY!

Complete the attached registration form and submit to UM CARD

Mail: 5665 Ponce de Leon Blvd ▪ P.O. Box 248768 ▪ Coral Gables, FL 33124-0725

Fax: 305-284-6555

Regional Training Registration Form

Please complete ALL sections of this form and submit. All confirmations and/or reminders will be sent via email.

Training Information

CARDCenter Hosting Training

Florida Atlantic University (FAU) CARD

Florida State University (FSU) CARD

University of Central Florida (UCF) CARD

University of Florida- Gainesville (UF GV) CARD

University of Florida- Jacksonville (UF JAX) CARD

University of Miami (UM) CARD

University of South Florida (USF) CARD

Training Title
Training Date

Registrant Information

No Acronyms Please

Name / Work Phone / ()-
School Name
or Employer / FAX / ()-
City / Home Phone / ()-
County / Email
Are you Out-of-Field? Yes No
*Out-of-Field refers to a teacher in a district school system assigned to teach outside the area in which he or she was certified

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Please use the legend below to complete the following information:

Job Title
School Type: / Class Type: / Certification:
Legend
Job title:
  1. Elementary Teacher (K-5)
  2. Middle School Teacher (6-8)
  3. High School Teacher (9-12)
  4. Multi-level Teacher (EL, MS, HS)
  5. Itinerant Teacher (K-12)
  6. PreKindergarten Teacher
  7. Student PK-12
/
  1. Family Member
  2. Paraprofessional
  3. Therapist (OT/ PT/ SLP)
  4. ESOL Teacher
  5. Title 1 Teacher
  6. District Program Staff
  7. Principal/ Assistant Principal
/
  1. Other School Professionals
  2. Behavior Specialist
  3. Social Worker
  4. Psychologist
  5. Counselor
  6. Nurse
  7. FDLRS Staff
/
  1. Project Staff
  2. Other Agency Staff
  3. Undergraduate Student
  4. Graduate Student
  5. In StateCol./ Univ. Staff
  6. Out of StateCol./ Univ. Staff
  7. Other School Support
/
  1. Bus Driver/ Aide
  2. Substitute
  3. Private Consultant
  4. DOE Staff
  5. Preservice Teacher

sCHOOL tYPE: / Class Type: / Certification:
AA.Private
AB.Charter
AC.Public
AD.N/A / BA.General Education
BB.ESE, NOT Autism
BC.Autism
BD.N/A / CA.General Education
CB.Varying Exceptionalities
CC.Other ESE
CD.Not Certified
CE.N/A