In Coordination with the Autism Society of Greater Jacksonville

in coordination with the Autism Society of Greater Jacksonville

FREE Regional Workshop in Duval County…Jacksonville

April 22, 2006

9:30a.m. – 1:00p.m.

Registration begins at 9:15a.m.

at Pump it Up

11840 Beach Boulevard, Suite 10

Jacksonville, Florida 32246

Pump it Up is located at 11840 Beach Boulevard, Suite 10. For directions from your residence, visit www.mapquest.com.

For more information contact: CARD at (904) 737-5239 or you can send an email to Jeannie Bowles at

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Be sure to contact your ESE District Staff or Staff Development Contact to determine the process for receiving in-service.

Registration Information

REGISTRATION IS MANDATORY……DEADLINE: April 19, 2006

Complete the attached registration form and submit to Jeannie Bowles at UF/Jax CARD

Email:

Mail: University of Florida at Jacksonville, CARD Center, 6026 San Jose Boulevard, Jacksonville, Florida 32217

Fax: 904-396-4718

*All confirmations and/or reminders will be sent via email

Regional Training Registration Form

Please complete ALL sections of this form and submit. All confirmations and/or reminders will be sent via email.

Training Information

CARD Center Hosting Training

Florida Atlantic University (FAU) CARD

Florida State University (FSU) CARD

University of Central Florida (UCF) CARD

University of Florida- Gainesville (UF GV) CARD

University of Florida- Jacksonville (UF JAX) CARD

University of Miami (UM) CARD

University of South Florida (USF) CARD

Training Title / Positive Behavior Support Strategies for Families
Training Date / April 22, 2006

Registrant Information

No Acronyms Please

Name / Work Phone / ()-
School Name
or Employer / FAX / ()-
City / Home Phone / ()-
County / Email
Are you Out-of-Field? Yes No
*Out-of-Field refers to a teacher in a district school system assigned to teach outside the area in which he or she was certified

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Please use the legend below to complete the following information:

Job Title
School Type: / Class Type: / Certification:
Legend
Job title:
1. Elementary Teacher (K-5)
2. Middle School Teacher (6-8)
3. High School Teacher (9-12)
4. Multi-level Teacher (EL, MS, HS)
5. Itinerant Teacher (K-12)
6. PreKindergarten Teacher
7. Student PK-12 / 8.  Family Member
9.  Paraprofessional
10.  Therapist (OT/ PT/ SLP)
11.  ESOL Teacher
12.  Title 1 Teacher
13.  District Program Staff
14.  Principal/ Assistant Principal / 15.  Other School Professionals
16.  Behavior Specialist
17.  Social Worker
18.  Psychologist
19.  Counselor
20.  Nurse
21.  FDLRS Staff / 22.  Project Staff
23.  Other Agency Staff
24.  Undergraduate Student
25.  Graduate Student
26.  In State Col./ Univ. Staff
27.  Out of State Col./ Univ. Staff
28.  Other School Support / 29.  Bus Driver/ Aide
30.  Substitute
31.  Private Consultant
32.  DOE Staff
33.  Preservice Teacher
sCHOOL tYPE: / Class Type: / Certification:
AA. Private
AB. Charter
AC. Public
AD. N/A / BA.  General Education
BB.  ESE, NOT Autism
BC.  Autism
BD.  N/A / CA. General Education
CB. Varying Exceptionalities
CC. Other ESE
CD. Not Certified
CE.  N/A