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Orientation & Mobility Seminar Toronto, ONJanuary 17th & 18th, 2017 Registration Form Name: Mr./Mrs./MS:Agency Name: Agency Address: City, Province, Postal Code:Daytime Phone:Evening Phone: E-mail Address: Title: Is this a residential program?___ Yes___ No If applicable, please list dates of previously attended seminars:Please provide us with some additional information about yourself and your agency. Where did you receive your O&M training? How many years have you taught O&M? What services do you provide? What age group do you predominantly serve? Approximately how many blind and visually impaired adults do you teach O&M skills to annually?Approximately how many blind and visually impaired clients does your agency serve annually?How many of your clients are independent travelers in all settings? Approximately how many hours of instruction do you spend with your average client? Have you ever worked with a guide dog team?___ Yes___ NoWill you be applying hours from this seminar towards ACVREP Continued Education Credits?___ Yes___ NoLunch is provided both days, so please indicate here whether or not you have any special dietary needs.Please return this form to Marc Gillard at mgillard@guidedogs.com orGuide Dogs for the BlindAttn: Marc Gillard O&M Services Specialist350 Los Ranchitos RoadSan Rafael, CA 94903 |
