EarlyStartDenverModel
IntroductoryWorkshopApplication
21BloomingdaleRoad
WhitePlains,NewYork10605
June9,2015
ApplicationswillberevieweduntilMay22,2015,oruntilallspaceshavebeenfilled. Program/TeamName:
NameofContactPerson:
Pleasecompletecontactinformationforyourselfandforallteammemberswhoare
applyingtoparticipateintheWorkshop:
MainContactName:
EmailAddress:
ProfessionalBackground/JobTitle:
BusinessPhone:
HighestEarnedDegree&Certifications:
HomePhone:
Language(s)Spoken:
MobilePhone:
MailingAddress:
TeamMember#2Name:
EmailAddress:
ProfessionalBackground/JobTitle:
BusinessPhone:
HighestEarnedDegree&Certifications:
HomePhone:
Language(s)Spoken:
MobilePhone:
MailingAddress:
2 TeamMember#3Name:
EmailAddress:
ProfessionalBackground/JobTitle:
BusinessPhone:
HighestEarnedDegree&Certifications:
HomePhone:
Language(s)Spoken:
MobilePhone:
MailingAddress:
TeamMember#4Name:
EmailAddress:
ProfessionalBackground/JobTitle:
BusinessPhone:
HighestEarnedDegree&Certifications:
HomePhone:
Language(s)Spoken:
MobilePhone:
MailingAddress:
Pleasetelluswhyyouareinterestedinparticipatinginthisworkshop.
3 Bysigningbelowyouacknowledgethat,ifacceptedfortheIntroductoryWorkshop,
youandallparticipantsinyourteam:
UnderstandEnglish(alltrainingwillbeprovidedinEnglish)
Havepurchased,readandwillbringacopyofthemanual,EarlyStartDenverModel
forYoungChildrenwithAutism:PromotingLanguage,Learning,andEngagement
Themanualisavailableforpurchasefromvarioussources,includingthese:
http://www.guilford.com/cgi‐bin/cartscript.cgi?page=pr/rogers6.htm
http://www.amazon.com/Early‐Start‐Denver‐Children‐
Autism/dp/1606236318/ref=sr_1_1?ie=UTF8&qid=1388277130&sr=8‐1
Havepurchased,readandwillbring1copyoftheEarlyStartDenverModel
CurriculumChecklist
Thecurriculumchecklistisavailableforpurchasefromvarioussources,including
these:
http://www.guilford.com/cgi‐bin/cartscript.cgi?page=pr/rogers7.htm
http://www.amazon.com/Denver‐Curriculum‐Checklist‐Children‐
Autism/dp/1606236334/ref=pd_bxgy_b_img_z
Willsubmitatrainingfeeof$500/memberpayabletoWeillCornellMedical
College/CADB.
AreliableforthetravelandaccommodationcoststoWhitePlains,NewYorkfor
training
Signed:____________________________________________Date:__________________________
Pleaseprintname:____________________________________________
Pleaseemailyourapplicationto:
MarcellaBello
[email protected]