Dr. Navsaria Registration Form

REGISTRATION FOR BOTH PRESENTATIONS IS NOW CLOSED. If you have any questions or want to see if there is current availability, please contact Bonnie Cowen: bcowen@ecclc.org. Thank you!

These presentations are funded through a grant from the Early Childhood Colorado Partnership and are at no cost to you.

We will be taking photos at our event for public promotion of the Leap Coalition.

For additional questions, please contact Bonnie Cowen (bcowen@ecclc.org).

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* I will be attending

Monday, September 11th, 6:00-8:30pm - Registration Closed!

Tuesday, September 12th, 8:00am-11:30am. - Registration Closed!

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* Contact information

Name (as you want printed on name tag) *

Name of business / agency

Email Address *

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* Choose what profession best describes your role

early childhood educator/caregiver

early childhood special educator

early childhood director

speech language pathologist

occupational therapist

physical therapist

mental / behavioral health provider

social worker

public health professional

family services professional

administrator

nurse

primary care provider

dentist

judicial / law enforcement

policy maker

community member

student

Other (please specify)

To help inform the presentation, please provide us with the following:

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* Do you work directly with children?

YES

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* Do you work directly with families?

YES

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* Do you provide home visits?

YES

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* We will be distributing a contact list with name/agency/email of all presentation attendees after the event. Please indicate if we may include your information on the contact list (to be shared only with event attendees).

Yes, you may include my contact information.

No, I prefer to NOT have my contact information included.

Dr. Navsaria Registration Form

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* I will be attending

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* Contact information

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* Choose what profession best describes your role

Question Title

* Do you work directly with children?

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* Do you work directly with families?

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* Do you provide home visits?

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* We will be distributing a contact list with name/agency/email of all presentation attendees after the event. Please indicate if we may include your information on the contact list (to be shared only with event attendees).

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* If you require any special accommodations, please explain in space provided below. We will do our best to work with you to accommodate your needs.

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* Additional comments: