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Event Title: _________________________________________________________
Event Date: _________________________________________________________
Location: ___________________________________________________________
Event Time: ________________________________________________________
Event Cost: ________________________________________________________
Sponsor Name*: _____________________________________________________
*This name should appear on Attendance Verification Form.
Sponsor Affiliation:
___ A) The Academic Language Therapy Association
___ B) ALTA affiliated therapist training programs
___ C) Organization concerned with dyslexia and related learning disabilities
___ D) University or college
___ E) Individual (attach appropriate credentials)
___ F) Other (if other, please attach appropriate documentation)
Number of Contact Hours* (required): ________
*One (1) Contact Hours = Sixty (60) minutes of direct instruction, lecture, seminar or practical teaching.
Topic Area(s): _______
___ 1) Language and/or learning disorder
___ 2) Applied multisensory practice and methodology
___ 3) Curricula in academic language therapy
___ 4) Research-medicine, psychology, eduction, linguistics
___ 5) Professional practice, related laws and/or ethics of practice
___ 6) Other: _____________________________________________________
Briefly describe program, goals, and/or projected outcomes:
Presenter(s), degree, title, & professional affiliation (If individual applying as sponsor, include vita)
1) ______________________________ 2) _______________________________
3) ______________________________ 4) _______________________________
Contact Person: ____________________________________________________
Mailing Address: ___________________________________________________
____________________________________________________________________
City: _____________________________ State: _________ Zip: __________
Daytime Phone: _____________________________________________________
For Continuing Education Subcommittee Use:
Date Received: ____________________ Agency Notification Sent: ______
Continuing Education Approved: _____ Notes: ________________________ |
