A "Thank You" for Taking This Step!!!

EC-TIIS is currently funded as a Phase 3 Steppingstones of Technology Innovation for Students with Disabilities project grant through the U.S. Department of Education Office of Special Education. As such, we require registration information from all participants.

Your information is confidential and will be used ONLY for research purposes in group format. We ask your name and address only for contact information. We will never use or reveal any of your personal information to any third parties.

There is no cost for these workshops. However, we require completion of registration and preliminary surveys to assist us in improving programs, planning future offerings, and in obtaining support for our services.

Thank you, in advance, for your cooperation. Your time and effort is greatly appreciated.

EC-TIIS Registration Form

Personal Information
1. Please tell us your name.

Mrs.

Mr.

Ms.

Dr.

Other

Last Name	First Name	Middle Initial

2. What is your mailing address?

Address

City

State

Zip Code

Country:

3. What is your email address?

4. Enter your password to use:

5. What is your Gender? (optional)

Female

Male

6. What is your age? (optional) Years

7. What is your race? (optional)

African American		Asian		Caucasian		Hispanic
Native American		Pacific Rim		Other

Professional/Personal Interest Information

8. How did you find the EC-TIIS Website?

I was given the website address via invitation.

I found it through the Center for Best Practices web site.

I found it through a search engine.

Another web site recommended it.

It was mentioned in a workshop or seminar.

I saw the EC-TIIS Brochure.

Other.

9. What is your position?

Administrator

Child Care Provider

Early Childhood Educator

Early Childhood Special Educator

Head Start Educator

Parent or family member
of a young child with a disability

Program Assistant

Support Personnel

University Faculty

University Student

Other

10. What kind of information are you most interested in? (check all that apply)

Adaptations	Family Participation
Computer Environment	Math/Science/Social Studies
Curriculum Integration	Software
Emergent Literacy	Technology Assessment
Expressive Arts	Other

To continue, check your information. If it is correct, click the submit button below.

Privacy Statement- We will never sell, trade, or otherwise distribute any of your information. Any information you provide to us is used solely by The Center for Best Practices in Early Childhood Education to help us in our continuing efforts to support our mission to provide equalizing opportunities for young children with disabilities.

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A "Thank You" for Taking This Step!!!

EC-TIIS Registration Form