Seattle Regional Public Education Forum – June 13, 2000

Registration Form

"Federal Policy—State Opportunities: Models and Strategies for an Inclusive Workforce"

(Print this registration form, complete all items and return to Kristi Beck as indicated below.)

You must return this form to Kristi Beck as soon as possible to be included on the formal participant list.

The information below will be used in the participant list. Please indicate the following as you wish it to appear in this document. Please type or print clearly.

Name:__________________________________________________________________________________

Professional Title:_________________________________________________________________________

Organization:_____________________________________________________________________________

Address:_________________________________________________________________________________

Telephone:____________________TTY:______________________Fax:_____________________________

E-mail:__________________________________________________

Please check all of the accommodations that apply:

___American Sign Language Oral/aural Interpreters

___Signed English Voice Interpreters

___Tactile Interpreters Pidgin Sign English

___Assistive Listening Devices (please specify)

Other (please specify)_________________________________________________________________________

___Braille ___Large Print ___Vegetarian

Please return this form ASAP to:

Kristi Beck , CESSI

Telephone: 703-448-6155 - Fax: 703-442-9015 or 703-448-3088

Email: beckkristi@earthlink.net