National Indian Parent Information Center

Pre-registration Sign In Sheet

Date_________________________________________________________________                                                                                    

Title_________________________________________________________________                                                                                   

Location_________________________

NAME

ADDRESS, CITY

ZIP

PHONE

Please include

Area code

TRIBE

PARENT?

PROFESSIONAL?

OTHER?         

          

CHILD'S

NAME/

AGE

CHILD'S

DISABILITY

EMAIL ADDRESS

 

 

 

 

 

 

STATE                            ZIP :

 

 

 

 

 

 

 

 

 

 

STATE                            ZIP :

 

 

 

 

 

 

 

 

 

 

STATE                            ZIP :

 

 

 

 

 

 

 

 

 

 

STATE                            ZIP :

 

 

 

 

 

 

 

 

 

STATE                            ZIP :

 

 

 

 

 

 

 

 

 

 

STATE                            ZIP :

 

 

 

 

 

 

 

 

 

 

STATE                            ZIP :

 

 

 

 

 

 

 

 

 

 

STATE                            ZIP :

 

 

 

 

 

 

 

 

 

 

STATE                            ZIP :

 

 

 

 

 

 

 

Return 5 weeks prior to workshop. We must have this before we can allocate funds for travel for the trainer.