Check here if you are a parent or caregiver of an affected child:

First:
Last:
Address:
City:
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Zip:
Daytime Phone:
Evening Phone:
Email Address:
Fax Number:
Occupation: Family DOH Staff Agency Staff Educator/School District Employee Home Care Provider/Supervisor Behavior Therapist Waiver Case Manager Respite Care Worker Private Therapist
School District or Agency:
Title:

I'm taking this course for:
Credit
CEUs
Non-Credit

I am taking this course under the auspices of a DOH provider program (enter agency name here):

Supervisor's Email Address:

I am enrolling in a free or non-payment course.

I understand that I am registering with the Autism Program to attend the Family and Communication Education (FACE) workshop. I also accept responsibility for the training fee ($65 per person, per workshop) and will make arrangements to send payment to the University of New Mexico.

My school district is assuming the cost of this course (provide Purchase Order below).
Purchase Order #: