Intelligent Lives Screening

Intelligent Lives Screening

A film by Dan Habib
September 26, 2019

5:30 p.m. Mini Resource Fair & Reception

6:00 p.m. Welcome & Film Screening

7:20 p.m. Panel Discussion
Name *

First Name Last Name
E-mail *
Please be extra careful when entering your e-mail address. This will be used to send event information and confirmations.
Daytime Phone Number *

Area Code Phone Number
School Name/Agency/Organization or Community Member *
Please enter your school name/organization here. Enter the complete name of your school/organization (please DO NOT abbreviate).
School Division (if applicable)
Please enter your school division here. Enter the complete name of your school division (please DO NOT abbreviate).
Special Accommodations (including dietary) *
Enter N/A if no special accommodations are required.
Photo Permission: Photographs and digital images may be taken during this training for purposes of educational illustrations, broadcast, publication, or distribution in any manner seen fit by the Training and Technical Assistance Centers of Virginia and / or other Virginia Department of Education initiatives. If you do NOT wish to be included in photographs and digital images, please notify staff upon your arrival at this event so we may make every effort to exclude you from photographs and digital images. *

Yes, I consent to my photo being taken No, I do not consent to my photo being taken
Demographics Form
Primary Disabilities Served (one or more) *

ADD/ADHD Autism Spectrum Disorder Blind Deaf-Blind Deaf Developmental Delay Emotional Disability Hearing Impairment Intellectual Disability Learning Disability Multiple Disabilities Orthopedic Impairment Other Health Impairment Speech-Language Impairment Traumatic Brain Injury Vision Impairment ALL
Title: (ONE ONLY) *

Administrator, General Education Administrator, Special Education Behavior Specialist College Student School Counselor Human Services Agency Staff Mental Health Specialist Occupational Therapist Paraprofessional Parent/Family Physical Therapist Pre-K – 12 Student Social Worker Speech Pathologist Teacher, General Education Teacher, Special Education Transition Coordinator University Faculty Vocational Teacher/Administrator
Program Affiliation: (one or more) *

Adult Education/Family Literacy Community-Based Preschool Early Childhood Special Education Early Intervention (B-3 yrs.) Even Start General (or Regular) Education Head Start Homeless Migrant Education Occupational Child Care VA Preschool Initiative School Age Special Education (K-12) Title I
Should be Empty:

Intelligent Lives Screening

Demographics Form