Assistive Technology Training Form

Contact Information
Referral Contact: Agency/School:
Street:
 
Town/City: State: Zip Code:
Telephone: Fax Number:
Email:
Learner Name: Age:

Web Site: www.PracticalATSolutions.com
E-mail: Phyl@PracticalATSolutions.com
Telephone: (802) 484-3537
Training Areas Description of Needs
Adapted Curriculum & Teaching  
 
 
Augmentative Communication   
 
 
Collaborative Team Building  
 
 
Control Interfaces & Switches  
 
 
Education & Vocational Supports  
 
 
Environmental Design
& Accomodations		  
 
 
Keyboard & Mouse Emulation  
 
 
Specialized Software Applications  
 
 
Other (please explain)  
 
 

Training Contact
Training Host: Training Location:
Street:
 
Town/City: State: Zip Code:
Training Host Telephone: Training Location Telephone:
Training Host Email:

Web Site: www.PracticalATSolutions.com
E-mail: Phyl@PracticalATSolutions.com
Telephone: (802) 484-3537
Training Goals
(Please be Specific)
1.
 
2.
 

Training Format
Inservice/Workship:
Number of Sessions   Number of Hours Per Session
Lecture/Classroom Styles   Hands-On Lab   Make & Take/Product Creation
Course Seiries:
Number of Sessions   Number of Hours Per Session
Lecture/Classroom Styles   Hands-On Lab   Make & Take/Product Creation
NOTE: For Hands-On Lab Sessions
  Technology Support Staff   E-Mail:
Type of Platform:   Windows:
Macintosh:		 List Operating System
List Operating System
Confrence Workshop Session Request:
Name of Conference: 
Location:
Conference Website: 

 Date of Conference: 
 Length of Session(s): 
 Topic: 


Referral Apprival
Administrator: Agency/Supervisory Union:
Street:
 
Town/City: State: Zip Code:
Telephone: Fax Number:
Administrator Email:
 
 
Administrator Signature (required) Date

Web Site: www.PracticalATSolutions.com
E-mail: Phyl@PracticalATSolutions.com
Telephone: (802) 484-3537