IDAC Registation Form

2010 In-District Autism Consultant Training (IDAC)

Training Information

A separate registration form is required for each person wishing to attend.

Name: In-District Autism Consultant Training

Date of training: January 25th through 27th, 2010

Identification Information

First Name:
Last Name:
Title or Position:
School or Organization:

Names and Dates of Previous Autism Specific Training
(A minimum of six days of autism specific training is required to attend!)

Training Workshop:	Date Attended:
Intro to Autism
Working with Autistic Students in Schools
Early Intervention for Young Children with Autism
Other (Subject to Approval) Please Describe:

Billing Address

Billing Address:
City:
State:
Zip:

Home Address

Home Address:
City:
State:
Zip:

Contact Information

E-Mail: (Required)
Work Phone:
Work Fax:
Home Phone:

Billing Information

Amount Sent by Mail:
Check Number:
Purchase Order Number:

Please check this checkbox to indicate that you have read and understood the cancellation policy.

Please make checks out to: Project ACCESS and mail to
Project ACCESS/MSU
901 S National Ave
Springfield, MO 65897

If you have not received a confirmation e-mail by one week prior to the training, CALL TOLL FREE:
1-866-481-3841 or email tina333@missouristate.edu for verification of your registration.

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