Name Date ________________
Phone Home Cell _____________________
Address ________________________________________________
Professional Credential/experience:
___ Years experience in teaching/working
___ Years experience teaching Learning disabled
___ Parent of student with unique learning issues
___ Other
___ Special education credential __________________ type
___ Speech Pathologist
___ Psychologist
___ Teacher
___ Therapist
Client/Patient preference:
___ Elementary ___ Middle/ high school ___ Adult
___ Learning disabilities ___ Autistic Spectrum ___ Dyslexia
___ ADD/ ADHD ___ Other
___ One-on-one teaching ___ Small group ___ Classroom
Assessment experience:
List instruments you usually use: __________________________________
List reading programs you usually use: _____________________________
Fee required for reservation: $475.00 (includes Assessment >therapy sourcebook)
___ Check enclosed ___ Bill Credit Card ___ Visa ___ MC
Credit Card # _______-_______-_______-_______ Exp Date ___/ ___
Credit Card billing address if different from above:
(No refund after March 15th - 50% credit may be applied to ltp material purchases)
Print this form and FAX it to Joan at 831 484-0998
or Mail to Learning Time Products at
14401 Roland Canyon Road, Salinas, CA 93908
Memory > Groups > Calming Kitchen Workshop
Advanced Techniques to Resolve Learning Disabilities
Enrollment Form
Advanced Techniques to Resolve Learning Disabilities
Enrollment Form