PACER Simon Technology Center Individualized Training Application

Student/Consumer Information

Question Title

* 1. This training is for a:

Child/Student Under 18

Adult/Consumer

Professional

Other (please specify)

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* 2. Student/Adult/Consumer Information

Name (First and Last)

Address

City

State

ZIP/Postal Code

Email Address

Phone Number

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* 3. Parent/Guardian/Primary Contact information (required for student under age 18):

First and Last Name of Primary Contact

Relationship

Address (if different from above)

City

State

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 4. Secondary Contact information (optional):

First and Last Name

Relationship

Address (if different from above)

City

State

ZIP/Postal Code

Email Address

Phone Number

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* 5. Preferred means of contact:

Phone Call

Text Message (by checking this you agree to receive occasional text messages regarding your training)

Specific directions for training communication:

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* 6. Primary Language

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* 7. If your primary language is not English, will you require a translator?

Yes - I would like PACER to provide a translator.

Yes - I will bring someone who can translate.

No - I do not require a translator.

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* 8. Age and/or date of birth for person attending training:

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* 9. Grade in school/school name (if applicable):

Question Title

* 10. Please list any additional individuals who will participate in the training (up to two additional participants may attend).

Please include each person's full name and email address.

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* 11. Would you prefer an in-person or virtual training?

We prefer an in-person training at the PACER Center.

We prefer to have a virtual training via Zoom.

We would like to decide once we speak to our specialist about scheduling.

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* 12. How did you hear about our training service?

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33% of survey complete.

PACER Simon Technology Center Individualized Training Application

Question Title

* 1. This training is for a:

Question Title

* 2. Student/Adult/Consumer Information

Question Title

* 3. Parent/Guardian/Primary Contact information (required for student under age 18):

Question Title

* 4. Secondary Contact information (optional):

Question Title

* 5. Preferred means of contact:

Question Title

* 6. Primary Language

Question Title

* 7. If your primary language is not English, will you require a translator?

Question Title

* 8. Age and/or date of birth for person attending training:

Question Title

* 9. Grade in school/school name (if applicable):

Question Title

* 10. Please list any additional individuals who will participate in the training (up to two additional participants may attend).Please include each person's full name and email address.

Question Title

* 11. Would you prefer an in-person or virtual training?

Question Title

* 12. How did you hear about our training service?

* 10. Please list any additional individuals who will participate in the training (up to two additional participants may attend).

Please include each person's full name and email address.