T.I.E.S. Registration Form

First Name

Last Name

Street Address

City

State

Zip Code

Email Address

Phone Number

School District

Name of School

Grade Level

Job

Credentials Held

A real-time captionist will be provided for all access needs.

If you have a hearing loss and need a real-time captionist, please indicate below.

Yes

No

Did you receive your Preliminary Credential before or after attending TIES for the first time?

Before

After

How many years have you attended TIES?

Which workshops do you plan to attend?

NOV 18: OBJECTIVE ASSESSMENT OF HEARING IN CHILDREN: IMPLEMENTING THIS INFORMATION

DEC 9: Device Fitting: Partnering with Your Audiologist

JAN 19: Soda Bottles and Submarines: Essentials of Speech Acoustics

FEB 17: Technology & Listening  

MAR 24: AVEd Strategies: Real Teachers in Real Classrooms 

MAY 5: No Hablo Ingles..Now What?: Coaching Parents in Bilingual Language Development

I am interested in obtaining CEUs through the A.G. Bell Academy for Listening and Spoken Language.

ONLINE PAYMENT

Please fill out this section if you wish to pay online through Google Checkout's secure payment website

If you pay at the door, the price is $60/workshop

# of workshops

$50 each: Advance payment (at least one week prior to workshop), $50 per workshop

Package of 6 workshops

$240: All 6 workshops at $40 each

# of Workshops for LSLS CEUs credit through AG Bell Academy

$5: LSLS CEUs credit through AGBell Academy, $5 per workshop

FINAL STEP

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Indicates Response Required

DHH Teacher	Regular Ed. Teacher	S/L Pathologist
Audiologist	Other

DHH	Single Subject
Multiple Subject	Special Ed.
Emergency Permit	Other