Prefix

First Name

Middle Name

Last Name

Birthday (01/01/2019)

Phone Number [ex: (123) - 4567]

Email (ex: myname@example.com)

Street Address

Street Address Line 2

City

State

Postal / Zip Code

Country

Gender Gender Male Female

Are you a US citizen? Are you a US citizen? Yes No

If not a US Citizen, tell us your country of origin

Highest Education Highest Education High School Bachelors Masters Doctorate

Major Area of Study (Please indicate what is your major area of study) Major Area of Study (Please indicate what is your major area of study) Child Development Teacher Education Family member of Rett Health & Physical Educator Medicine/Pre-Medicine Music Education/Therapist Nursing Occupational Therapist Paraprofessional Parent of child with Rett Physical Therapist Secondary Teacher Education Speech Therapist OTHER

If other, please tell us your area of expertise:

How many years have you had in your field?

You work: You work: Full-time Part-time

What has been your experience with children with Rett Syndrome? Delineate the highlights of your successful experiences teaching individuals with Rett Syndrome.

How many individuals with Rett Syndrome have you worked with How many individuals with Rett Syndrome have you worked withMore than 5More than 10More than 20

Have you ever presented a workshop? Have you ever presented a workshop? Yes No

If yes, what was the title(s) of your workshop and where did you present?

Do you have a video of yourself working with an individual with Rett Syndrome that can be a part of your webinar? Do you have a video of yourself working with an individual with Rett Syndrome that can be a part of your webinar? Yes No

If yes, please provide link to video

What topics would you like to present?

What are a few main points of your topic(s)?

What are your main learning objectives?

What is your expertise level with technology? ( video editing, file management etc.) What is your expertise level with technology? ( video editing, file management etc.) Beginner ( I need a lot of help ) Intermediate ( I need some support, video training, how to guide ) Advanced ( I have created on-line webinars before - I am sure I can figure this out )

Comments

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