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BUILDING BRIDGES_

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BUILDING BRIDGES_ Powered By Docstoc
					        ASERT, Eastern Region, Lehigh University Team
             (Autism Services Education Research & Training)
                         ASERT is funded by the Bureau of Autism Services, PA DPW

 Functional Behavioral Assessment and Treatment Plan Development

                             REGISTRATION FORM
                                   Deadline for Registration: April 15, 2011
I am interested in attending (please select only one training):

________        Southeastern PA:        April 20, 2011 & May 25, 2011 at Devereux, Villanova, PA

________        Lehigh Valley:          April 26, 2011 & May 17, 2011 at Lehigh University, Bethlehem, PA

                    Registration 8:30am – 9:00am                     Training 9:00am – 4:30pm

PLEASE PRINT CLEARLY

____________________________________________________              __________________________________________________
First Name              Last Name                Degree           Agency


____________________________________________________              __________________________________________________
Agency Address                                                    City             State                    Zip Code


____________________________________________________              __________________________________________________
Agency Phone Number                                               Agency Fax Number


___________________________________________________________________________________________________________
Email Address ** (Required)**

Have you previously attended this training? (circle one)          YES      NO
       If yes, did you pass the exam?                             YES      NO

Is this training required for your job? (circle one)              YES      NO


*NO CEUs ARE AVAILABLE FOR THESE TRAININGS
*REGISTRATION IS LIMITED TO 25 PER SESSION
*IT IS A REQUIREMENT THAT YOU ATTEND BOTH TRAINING DAYS

Please fax or email the completed form(s) to Cathy Kunsch at 610-758-6223 or to the following email
address ckunsch@lehigh.edu . If you have any questions, please contact Cathy Kunsch at
PH: 610-758-5826 or ckunsch@lehigh.edu .

PLEASE NOTE: You will receive an email confirming your registration for the training. You are
not registered until you receive this confirmation. In this email, you will receive: directions to the
training site, reminder of dates/times, and copies of the training materials. It is your responsibility to
print the necessary training materials. Training materials will NOT be provided.

				
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posted:10/19/2011
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