[dynamichidden form-type "registration"]

All red asterisk * are required fields.

First Name *
[dynamictext* first-name "wpm_username"]

Last Name *
[dynamictext* last-name "wpm_userlastname"]

Your Email *
[dynamictext* your-email "wpm_useremail"]

Alternate Email

Address *

City *

Province *

Postal Code *

Phone *

Alternate Phone

Please indicate your role: *
Teacher-in-trainingEA / SEA / CEA studentCommunity support (describe below)Parent / family

Provide some information about your role,
program of study, etc:

Level of student(s) with whom you work
(choose only ONE - if both apply, select the
level with which you work the most): *
Elementary / Middle SchoolSecondary

Do you currently work directly with a child
/ children with ASD?
If ``yes``, please describe below: *
YesNo

Describe your experience working with a
child / children with ASD:

In 2 or 3 sentences, explain why you are
interested in taking this course:

Which session of the Introduction to Autism
Spectrum Disorders - Practical Applications
course are you applying for?: *
June 19-23, 2017 (8 remaining)

REMINDER: THIS IS AN APPLICATION ONLY. SUBMISSION OF THIS FORM DOES NOT CONSTITUTE REGISTRATION.
YOU WILL BE CONTACTED BY POPARD TO PROCESS YOUR REGISTRATION AND PAYMENT IF YOUR APPLICATION IS
APPROVED.

Terms of service for course registration:

Course Registration/Administration Fees are non-refundable.

Course attendees must attend the entire training session in order to receive a certificate of participation.

I agree to the terms of service for course
registration:
Yes

[dynamichidden user_id "wpm_userid"]
[dynamichidden course_id "wpm_courseid"]