ICN Registration Form

The University of Iowa
Regional Autism Services Program
Child Health Specialty Clinic

ICN Registration Form

Deadline for registering is 4 days before the event to assure seating and CEU certificates.

You may register for one or both September events in one submission.

* Denotes required field for successful submission.

*First Name
*Last Name
*E-mail Address
	You will receive a confirmation of your registration at the e-mail address you supply above.
*Agency
*Position
*Address

*City in Iowa
*Zip Code
*CEU/attendance certificate Interest
	NOTE: If you don't indicate a desire for any certificate at this time, we won't be able to accommodate requests later.
*License Number (if Social Work or Speech Pathology CEU selected)
*Daytime Phone

First select a Topic, then select a Location.
Topic
Location

Unable to attend; send me the lending library copy of Best Practices in ASD Birth to Eight. I will return it UPS.
Unable to attend; send me the lending library copy of Methods of Intervention for ASD. I will return it UPS.

To locate the specific address of the ICN classroom site, go to http://www3.iptv.org/iowa_database/ and click on "find a classroom".

We will be contacting someone from each site to act as host to respond to roll call and distribute materials.

If you don't see an ICN site of preference, we have already reached the seating capacity limit for that site. If you would like to be placed on a waiting list for a site, please contact Sue Baker at 319-356-4619 or sue-baker@uiowa.edu.

If you want to consider adding another site at your expense (transmission and room charges) it must be available for 3 or more participants on both September 22 and 29. Please contact Sue Baker at 319-356-4619 or sue-baker@uiowa.edu to schedule it by September 16.

If something comes up after registration, please be courteous in letting us know if you are unable to attend, so we can utilize our waiting list.

Registrants will need to bring their own handout to the events. You may download the handouts at http://www.medicine.uiowa.edu/autismservices/icnhandouts.htm.

We will cancel sites where no one has registered by the deadline of four days before the event.