ESDM Introductory Workshop Application
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 mab9254@med.cornell.edu
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