Registration Form   

Name: ______________________________________________    Telephone: _____________________________________

Agency/Position: ______________________________________    Fax:  __________________________________________

Mailing Address: ______________________________________    E-Mail: _________________________________________

                           ______________________________________

Circle the days that you will attend:

Oct. 10 & Oct. 17 (day 1 & 2) for adult education teachers, tutors and counselors, 

Oct. 24 (day 3) for anyone interested in adult dyslexics

If you attend days 1 and 2, you will be able to keep the four books used in the training and will receive a certificate of attendance for the Bridges to Practice part of the workshop.  Also the number of participants is limited to 40 during the first two days because we have a limited number of books.  If you sign up for the first two days, you are committing to complete the Bridges to Practice Training on Friday, Oct. 10 and Friday, Oct. 17 from 9 am to 4 pm, each day. The third day is not based on the “Bridges to Practice” texts, and therefore is not limited to the first 40 people who register.

Participant Signature ­ ____________________________________________                 Date  - _____________________________  

1.  What do you hope to learn from these sessions?  

2.  Have you had any coursework specifically related to learning disabilities?

¨ No                        ¨ Yes (If yes, please describe briefly.