Registration
Download PDF copy here: http://ec3-registration.
To Register
Please complete and return both pages
Registration without the attendee’’s signature will not be processed
Attendee Information
First Name: ________________________Last Name:___________________________
Suffix:_____VP/IP: ______________________ Phone:__________________________
Address:_______________________________________________________________
City: _____________________State/Province: ___________IP Code:______________
Work email: ____________________Pager email/text#:_________________________
Program Information
School/Program: ________________________________________________________
Address: _______________________________________________________________
City: ______________________State/Province: _________ZIP Code:______________
Country: _______________________________________________________________
Position: _______________________________________________________________
For working groups, please select: ____(0-3); ____ (3-5); ____ (5-8): ____ (0-8)
Meal Requests
(all special requests must be made in writing by March 1, 2012) you may be contacted for clarification
Vegetarian: __________Vegan: __________Gluten Free: ______Diabetic: __________
Other (please specify): _______________________________________________________
Communication Access Needs (Summit will be conducted in ASL.)
Please check: ___Deaf/Blind Interpreter ___Spanish Interpreter ___Spoken English Interpreter
Payment Information
Registration fee: $150 per person.
Includes breakfast and lunch, printed materials and souvenir kit.
Seating is limited to 150 participants only so registrations will be accepted on a first come, first served basis.
Deadline for Registration is February 29, 2012
No refunds will be given after March 1, 2012
Form of Payment: Check #: ___________PO #:_______________
Checks Payable to: Statewide Programs for the Deaf, Hard of Hearing and Deaf Blind
Purchase Orders must be received no later than March 1, 2012. Attach a copy of the purchase request.
Submitting your paperwork
All paperwork must be submitted to the following address: ATTN Debbie Trapani, Statewide Programs for the Deaf, Hard of Hearing and Deaf Blind, 630 E. Chestnut Hill Road, Newark, DE 19713
Completed registration forms & Purchase orders may be emailed to: ECE.SUMMIT@gmail.com.
Permission for Release
The complete contents of this form are to be read by–or translated into American Sign Language (ASL), as appropriate–the National American Sign Language & English Bilingual Consortium for Early Childhood Education (ECE). The Consortium’s Project is designed to provide training, action research and curriculum development for ECE professionals in Deaf Education.
Final Products
The final product of the videotape will be used as part of the training and curriculum. The Project will not receive any payment from this product. The original videotapes will become the property of the Consortium and used for pre-service and in-service training purposes. If you have any questions or concerns, you may contact the Consortium Board at ECE.Summit@gmail.com.
Agreement by the Summit Participant
I, the undersigned, do hereby consent and agree that the Consortium, or its agents have the right to take photographs, videotape, or digital recordings of me beginning on and ending on the dates of the entire Summit and to use these in any and all media, now or hereafter known, and exclusively for the purpose of the Consortium. I further consent that my name and identity may be revealed therein or by descriptive text or commentary. I do hereby release to the Consortium and its agents all rights to exhibit this work in print and electronic form publicly or privately. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used. I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback. I also understand that is not responsible for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to any sickness or injury incurred as a result. I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.
Signature of Participant
I have read and/or had translated into ASL the above information. My signature below indicates that I understand the above information, agree to participate in the Project, and release videos/photos of myself and/or documents to the Consortium for use in this Project.
Name (print or type)___________________________________________________________________
Signature ___________________________________ ______________Date ______________________
