EACH PERSON ATTENDING THE CONFERENCE MUST REGISTER SEPARATELY.

First Name:                             *

Last Name:                             *

Email address:                        *

County / School District:         Choose One Out of State Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia DeSoto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Miami-Dade Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Santa Rosa Sarasota Seminole St. Johns St. Lucie Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington *

Role:*         Parent          School District Employee / Professional         Other

- - - - - - - Complete this section only if School District Employee / Professional  - - - - - - -

        Position:                       Choose one Agency Personnel / Service Provider Discretionary Project Personnel District Staff Itinerant Teacher Paraprofessional PK Teacher Related Service Provider School Administrator School Support Staff State Personnel Teacher University Faculty University Student

        Work Location:           
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Street Address:                   *

Address Line 2:                  

City:  *       State:  *         Zip:  *

Home Phone:                     

Work Phone:                      

  I would like to schedule an IEP Clinic* appointment.
        (*a brief one-on-one introductory consultation with an IEP Support Parent).

  I would prefer to attend workshops in Spanish.

  I will need special accommodations: