1248
Page 1 of 2
Georgia PINES/GSAP Parent-Professional Workshop Registration Form
March 16, 2013
At the Atlanta School for the Deaf
890 North Indian Creek Drive
Clarkston, GA 20021
Download Workshop Flyer Here
Download Workshop Agenda Here
Download SIBSHOP Information/Registration
PARTICIPANTS:
A discount will automatically be applied on the next page for two or more registered Parents/Guardians/Grandparents (two for $15.00).
PARTICIPANT 1
PARTICIPANT 2
NAME
ADDRESS
EMAIL
PHONE
Choose One
GA Pines Parent/Guardian - $10.00
GA Pines Grandparent - $10.00
BCW - $25.00
EI Agency - $25.00
School System - $25.00
Parent Advisor - $10.00
Other - $25.00 (describe below)
ROLE
Choose One
GA Pines Parent/Guardian - $10.00
GA Pines Grandparent - $10.00
BCW - $25.00
EI Agency - $25.00
School System - $25.00
Parent Advisor - $10.00
Other - $25.00 (describe below)
OTHER
CHILD NAME
CHILD AGE
Enrolled in GaPINES
Not Enrolled in GaPINES
CHILD STATUS
Enrolled in GaPINES
Not Enrolled in GaPINES
PARTICIPANT 3
PARTICIPANT 4
NAME
ADDRESS
EMAIL
PHONE
Choose One
GA Pines Parent/Guardian - $10.00
GA Pines Grandparent - $10.00
BCW - $25.00
EI Agency - $25.00
School System - $25.00
Parent Advisor - $10.00
Other - $25.00 (describe below)
ROLE
Choose One
GA Pines Parent/Guardian - $10.00
GA Pines Grandparent - $10.00
BCW - $25.00
EI Agency - $25.00
School System - $25.00
Parent Advisor - $10.00
Other - $25.00 (describe below)
OTHER
CHILD NAME
CHILD AGE
Enrolled in GaPINES
Not Enrolled in GaPINES
CHILD STATUS
Enrolled in GaPINES
Not Enrolled in GaPINES
ADDITIONAL FAMILY ATTENDING NOT LISTED ABOVE:
No additional family members
1 additional family member not listed above - $5.00
2 additional family members not listed above - $10.00
3 additional family members not listed above - $15.00
4 additional family members not listed above - $20.00
5 additional family members not listed above - $25.00
ADDITIONAL NEEDS
Sign Language Interpreter:
No
Yes
Large Print:
No
Yes
Spanish Interpreter:
No
Yes
Other:
CONTACT INFORMATION RELEASE
I agree to share my contact information with other participants in the workshop:
No
Yes