Author: Helen Keller
Last saved by: nancy.odonnell
Company: HKNC

Helen Keller National Center
for Deaf-Blind Youths and Adults
National Training Team Professional Training Program
2010 - GENERAL APPLICATION FOR PROFESSIONAL TRAINING PROGRAM

APPLICATION MUST BE RECEIVED THREE WEEKS IN ADVANCE OF SEMINAR
Cost of seminars*:
3-day seminars: $375; 4-day Seminars: $500; 5-day Seminars: $550
*Includes lodging, meals, professional training and manual
Payment does not need to accompany application

Name of Seminar I wish to attend: __________________________________________________________________
                                                                                                                                   
Date of Seminar:  __________________________________________________________________

IDENTIFYING INFORMATION  (please print or type)
NAME    (first, last) |
EMPLOYER |
STREET ADDRESS |
CITY, STATE, ZIP CODE |
TELEPHONE/ TTY | (work)		                 	    (home)
E-MAIL |

EMPLOYMENT INFORMATION (Start with your present position)
ORGANIZATION | POSITION | FROM | TO

Expectation for this seminar:  Please consider your present or envisioned role in providing services to deaf-blind youths and adults:

Please complete both pages of this application and mail to:
	Sr. Bernadette Wynne or Doris Markham
	Helen Keller National Center
	141 Middle Neck Road
	Sands Point, NY  11050
V - 516-944-8900 ext. 233, TTY 516-944-8637, Fax 516-944-7302
www.hknc.org             ntthknc@hknc.org 

HKNC Seminar Application: Please fill in all that apply:
INFORMATION

Training Manual Format:  Please indicate preference.	(CDs available upon request)
CD _____   Regular Print ______      Braille ______       Large Print  ______     Font Size _____

Assistive Listening Devices available upon request.  Please indicate preference.
FM ______	         Infrared______	     Other _____________________________________

Preferred Spoken Language (if not English) __________________________________________

Are interpreting services required?    Yes      No	Indicate communication preference.
         
ASL						Fingerspelling only
English Contact (formerly PSE)		Oral/Aural
Signed Exact English		           Tactile
Other                                  
If you request this service you must notify us 28 days prior to the seminar or we may not be able to secure appropriate interpreters.  Cancellation policy:  A minimum of 3 business days cancellation notice prior to start of seminar or a 1 day interpreter fee will be passed on to you.

Are you familiar with any means of manual communication?    If yes:   (circle appropriate response)

Sign Language			1) Beginner 		2) Intermediate 	3) Skilled  

One-hand manual alphabet        1) Beginner 		2) Intermediate 	3) Skilled

Experience with Tactile Sign Language   (circle one)           Yes                    No

Will you require a room in the residence for this seminar?	Yes	              No

IF YOU REQUIRE ROOM ACCOMMODATIONS IN THE RESIDENCE YOU MUST COMPLETE THIS SECTION   Please circle:	        Male		Female

Do you have any dietary restrictions?  	          Yes	No  	If yes, describe: _______________ 

Do you have any additional needs?		Yes	No  	If yes, describe: ______________ 
                                                                            
_____________________________________________________________________________

Arrival date and time: ___________________________________________________________    

Departure date and time:  ________________________________________________________

Cancellation Policy: Please notify us two weeks prior to start of seminar.

Date: ___________		Signature of Applicant: ________________________________________

Signature of Supervisor:

Rev. 10/03/2008 dm

Rev. 11/16/07