2018 SCERTS application
2018 SCERTS Training Application and Agreement
"Implementing the SCERTS Assessment Process to Guide Program Development" May 3 & 4 2018
Submission of this form serves as an application to participate in a 2-day SCERTS training with Amy Laurent, Ph.D., OTR/L, sponsored by the Maine Autism Institute for Education and Research. Preference will be given to teams of 4 or more from a school/agency. Submitting this form indicates your school/agency commitment to two days of training for ALL team members. Cost is $100 per team member and includes two days of training, continental breakfast each day, handouts, and follow-up with the SCERTS trainer. You will be notified of acceptance to this training by email on or before December 15, 2017. Upon acceptance, you will asked to provide Purchase Order or billing information.
Please provide the following information
School/Agency:
*
School District (if applicable)
Schools represented in the district (if applicable)
Supervisor/Superintendent
*
Address
*
City/Town
*
State
*
Zip Code
*
Contact person for this application
*
First
Last
Email
Phone
Position
*
Total student population
*
Number of students with IFSP/IEP
*
Number of students diagnosed with Autism Spectrum Disorder
*
Does your district/agency have an in-house program that specializes in autism?
*
Yes
No
Does your district/agency have an in-house day treatment program?
*
Yes
No
Attendees must be identified at time of application.
Please provide this information below.
Attendee #1: Name
*
First
Last
Position/discipline
*
Email
*
Phone
Number of years working with individuals with autism
*
Grade level(s) Attendee #1 serves- choose all that apply
*
Early Intervention (0-3 yrs)
Preschool (3-5yrs)
Grades K-3
Grades 4-8
High School
Young adult/adult
Attendee #2: Name
First
Last
Position/discipline
Email
Phone
Number of years working with individuals with autism
Grade level(s) Attendee #2 serves- choose all that apply
Early Intervention (0-3 yrs)
Preschool (3-5yrs)
Grades K-3
Grades 4-8
High School
Young adult/adult
Attendee #3: Name
First
Last
Position/discipline
Email
Phone
Number of years working with individuals with autism
Grade level(s) Attendee #3 serves- choose all that apply
Early Intervention (0-3 yrs)
Preschool (3-5yrs)
Grades K-3
Grades 4-8
High School
Young adult/adult
Attendee #4: Name
First
Last
Position/discipline
Email
Phone
Number of years working with individuals with autism
Grade level(s) Attendee #4 serves- choose all that apply
Early Intervention (0-3 yrs)
Preschool (3-5yrs)
Grades K-3
Grades 4-8
High School
Young adult/adult
Attendee #5
First
Last
Position/discipline
Email
Phone
Number of years working with individuals with autism
Grade level(s) Attendee #5 serves- choose all that apply
Early Intervention (0-3 yrs)
Preschool (3-5yrs)
Grades K-3
Grades 4-8
High School
Young adult/adult
Thank you for your application. Be sure to hit "Submit" to assure we receive your application.
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2018 SCERTS application