SEMINAR APPLICATION

updates: last modified 06/02/2008

 

When you have completed the form below, please click the "SUBMIT" button below. For assistance ONLY with the functionality of this form, call Information Services at 516-944-8900 Ext. 253 (Voice/TTY). For more information about the seminar please contact Doris Markham directly at 516-944-8900 Ext. 233/239. 

 

***Applications MUST be submitted 3 weeks in advance of the seminar***

Payment is NOT required with this application.

 

Cost of 2008 Seminars: Full week-$500 which includes lodging, meals, professional training and manual.

                                            (Cost of 6-day Orientation and Mobility seminar - $550)

                                      

For More Information, contact:

National Training Team (NTT)

Helen Keller National Center: 141 Middle Neck Rd. Sands Point, NY 11050

516-944-8900 Ext. 233/239 (Voice)

516-944-8637 (TTY)

516-944-7302 (FAX)

ntthknc@aol.com

GENERAL 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:  
Fax with Area Code:
E-mail:

Employment information:

(Start with your present position)

  
ORGANIZATION POSITION FROM TO

 

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

 

INFORMATION - Please fill in all that apply:
Please indicate preference of info format: (required)

*Disks available upon request - please call

   Other  

Assistive Listening Devices available upon request. Please indicate preference:

  

FM    Infrared      Other  
 

Preferred Spoken Language (if applicable):   Other

Are interpreting services required?

(required)

 Yes No
If yes, please indicate communication preference:
Other, please explain:
If you request the above 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

Will you require a room in the 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:    
Cancellation Policy: Please notify us 2 weeks prior to start of seminar.

Copyright © 2008 Helen Keller National Center. All rights reserved.