T/TAC Home

Training Registration Form

Please note that submission of this online form is for trainings provided only through VCU TTAC in the Richmond area.
(PLEASE PRINT)

Name of Training Event:
Date (mm/dd/yy):

Training Location ( Please check one): Blackstone Chester Petersburg
Richmond Prince George South Hill Other

Your Name:

School/Agency/Program You Represent:
(Check all that apply): LEA EIA SOP LICC Multiple (more than one program) Other

Please indicate where you want training information sent. This information may be
used for the transmission of time sensitive information such as confirmations, receipts, workshop materials, etc.

Address:

City: State :
Zip Code:

Phone (ex 804-###-####): Fax (ex 804-###-####): Email:

Dietary restrictions? Vegetarian Other (please specify):

Please Complete Each Column (Check All That Apply)

Type of service Provider:
General Ed Administrator
Special Ed Administrator
Guidance Counselor
Human Service Agency Staff
Occupational Therapist
Paraprofessional
Parent/Family
Physical Therapist
Speech Pathologist
Teacher, General Education
Teacher, Special Education
Transition Coordinator
University Professor/Student
Vocational Teacher
Other

Program Affiliation:
Adult Ed & Literacy
Early Childhood Special Ed
Early Intervention
Even Start
General Education
Head Start
Homeless Education
Migrant Education
Occupational Child Care
Preschool Initiative
School Age Special Ed
Title I
Other

Main Disability Area Served:
ADD/ADHD
Autism
Deaf Blind
Deafness
Developmental D
Emotional Dist
Hearing Impair
Learning Dis
Mental Disability
Multiple Disab
Orthopedic
Other Health
Severe Disability
Speech/Lang
Traum Brain Inj
Vision Impair

FEE & PAYMENT INFORMATION
Total Fee(s):
Make Check payable to VCU T/TAC
Our FIN# is 54-6001758
DO NOT SEND CASH (cash payment must be made in person)

Check All That Apply:
Purchase Order #:
School Check :
Invoice Required
Personal Check

Send completed form(s) to: VCU T/TAC, Attn: Cheryl Bishop

Click on submit to send entry form online.

By Mail:
P.O.Box 842020
Richmond, Va 23284

By Fax:
804.828.7495

By Email Attatchment:
sswright@vcu.edu

**If you are a person with a disability and require any auxiliary aides, services, or other accommodations to attend a VCU T/TAC event, please contact Cheryl Bishop using the information above

VDOE Training and Technical Assistance Center @ Virginia Commonwealth University Partnership for People with Disabilities \| School of Education Region 1: 10 E. Franklin St. - Suite 200, Richmond, VA 23219 (804) 828-6947 Region 8: Pickett Park, 440 QM Circle, Blackstone, VA 23824 (434) 292-3723 Copyright � 2007 VCU Training and Technical Assistance Center \| Last Update: February 12, 2008