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2015 AUTISM AND ARTS EDUCATION SYMPOSIUM
PRESENTER and speaker Registration
DATES:
April 24, 2015, 4:00 - 8:00 PM
April 25, 2015, 8:00 AM - 5:00 PM
*
Indicates required field
Name
*
First
Last
First name (to appear on badge)
*
If different than above.
Email
*
Phone Number
*
Website URL
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
School, institution or business affiliation:
*
Role in autism or arts education (click all that apply):
*
Parent of a child with autism
Family member of someone with autism
Art educator
Art therapist
Drama educator
Drama therapist
Music educator
Music therapist
Special education teacher
Support personnel
Teaching artist
University faculty
Researcher
College student (UNI)
College student (non-UNI)
UNI Students Only: Are you volunteering at the symposium or a buddy in the Spectrum Project
Other
*
College Major
*
If in college, what is your major?
If associated with education, indicate teaching level(s)
*
Pre-K / Early childhood
Elementary
Middle School / Jr. High
High School
College/University
Other
*
Professional organization affiliations (click all that apply):
*
American Alliance for Theatre and Education
American Art Therapy Association
American Music Therapy Association
Association of Teaching Artists
Council for Exceptional Children
Educational Theatre Association
Iowa Alliance for Arts Education
National Art Education Association
National Association for Music Education
National Association of Special Education Teachers
North American Drama Therapy Association
Other
*
Certifications you currently hold:
*
Please list any certifications you currently hold:
Dietary considerations:
*
Friday dinner and Saturday lunch will be provided at no cost to you.
Comments
*
PHOTO RELEASE
I give permission to the University of Northern Iowa to use, publish and copyright, in any form, all photographs (including but not limited to, stills, slides or transparencies) and video footage in official university publications, video productions, Web use or for official university purposes.
Choose One
*
Yes
No
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