CVI Training Registration - 12.14.18

REGISTRATION FORM - Dr. Christine Roman-Lantzy - CVI Workshop, 12/14/18

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your email address?

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* 4. What is your mailing address?

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* 5. What is the best way to contact you? List Phone Number in Comment Field.

Voice/Phone

Text Message

Best Phone Number:

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* 6. Please list your employer (if school, name district as well):

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* 7. Please list your position title:

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* 8. In regards to this training, do you have a particular child in mind who has CVI?

Yes

No

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* 9. Do you have special dietary needs? If yes, please describe (If NO, put N/A):

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* 10. Do you have any special communication needs? If yes, please select all that apply (If NO, put N/A) NOTE: This request MUST be made by November 29, 2018:

N/A

ASL Interpreter

Braille

Large Print

Electronic Handouts

Other (please specify)

Please click on the word "Done" to submit your registration form.
We will email a confirmation of registration to you shortly.