SELF-STUDY | Feeding Foundations: The Kaleidoscope Model™ Note: You must complete this form in order to earn CEUs, and to receive your certificate of completion. 12/02/2024Date* MM slash DD slash YYYY Name* First Last Email Address* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Telephone*(ex., 555-123-1234)What is your profession?*Do you need TalkTools to report ASHA CEUs for you?* Yes No ASHA #*ASHA number is required if you want TalkTools to submit CEUs to ASHA on your behalf -- see TalkTools CEU Policy and Process https://talktools.com/pages/talktools-ceus-policy-and-process for more info. Type in N/A if you do not need ASHA CEUs.Are you an AOTA member?* Yes No Have you taken a TalkTools training before?* Live Workshop Virtual Live Workshop Online Learning/Self-Study Live Webinar Exceptional Child Empowered Conference Feeding First Conference OMD Deconstructed Conference N/A -- haven't taken TalkTools courses before Would you or your organization be interested in hosting a workshop in your area?* Yes No Want more info? Follow this link: https://talktools.com/pages/host-a-workshopAre you interested in pursuing TalkTools Level Training Program* Yes No Maybe For more information visit https://talktools.com/pages/talktools-level-training-program-updatedHow well do you think you have achieved the course learning outcomes?* Very well Fairly well Not well How helpful did you find the course resources?* Very helpful Fairly helpful Not helpful How likely are you to take another course with this instructor ?* Very likely Fairly likely Not likely How satisfied are you with the course learning environment?* Very satisfied Fairly satisfied Not satisfied What can TalkTools do differently that would improve your learning experience?*What do you plan to do with the knowledge gained from this course?*May we use your name and comments in our marketing campaigns?* Yes No Terms and Policy* I have read and understand the TalkTools Course Completion and CEU Policy Learn more: https://talktools.com/pages/talktools-ceus-policy-and-processFAQs* I have read and understand TalkTools Training FAQs Learn more: https://education.talktools.com/e-learning-faqs/