NTT SEMINAR APPLICATION

 

When you have completed the form below, please click the "SUBMIT" button below.

 

For more information about the seminar please contact Doris Markham directly at 516-944-8900 Ext. 233. 

 

Applications MUST be received 3 weeks in advance of the seminar you wish to attend

 

Payment is NOT required with this application.   

                                    

APPLICATION FOR PROFESSIONAL TRAINING SEMINARS

Please provide the following information:

Name of Seminar you wish to attend: (required)

First Name: (required)
Last Name: (required)
Employer: (required)
Mailing Address: (required)
City: (required)
State/Province: (required)
Zip/Postal Code: (required)
Home/Work Telephone with Area Code: (required)
  Ext.    
Other Telephone with Area Code:  
VP:
E-mail:
EMPLOYMENT INFORMATION

Employment information:

(Start with your present position)

  
ORGANIZATION POSITION FROM TO

 

Supervisor's name:
Sup. contact #:

LODGING/MEALS
Will you require a room in the HKNC residence for this seminar? (required) Yes No
Gender: (required) Male Female
Do you have any dietary restrictions? (required) Yes No      If yes, describe:
Do you have any additional needs? (required) Yes No      If yes, describe:
Arrival date and  approximate time to HKNC:    
Departure date and approximate time from HKNC:    
 
INFO/ACCESSIBILITY
Please indicate preference of info format: (required)

*CDs available upon request - please call

  

Other  

Assistive Listening Devices available upon request. Please indicate preference:

  

FM    Infrared      Other  
 

Preferred spoken language (if not English):   Other

Are interpreting services required?

(required)

 Yes No
If yes, please indicate communication preference:
Other, please explain:
If you request interpreting services, you must notify us 28 days prior to the seminar or we may not be able to secure appropriate interpreters.

Cancellation policy: A minimum of 3 business days cancellation notice prior to start of seminar or 1 day interpreter fee will be passed on to you.

Are you familiar with any means of manual communication? Please check the appropriate boxes: (required) Sign Language:

One-hand manual alphabet:

Experience with Tactile communication?: Yes No

Expectation for this seminar: Please consider your present or envisioned role in providing services to deaf-blind youths and adults.  

 

Interpreter Seminar Participants only: I am willing to be contacted after the training for follow-up program evaluation: Yes No
 
Cancellation Policy: Please notify us 2 weeks prior to start of seminar.

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Copyright © 2012 Helen Keller National Center. All rights reserved.

Updates: last modified 01/25/2012