Gravity Form to e-signature-Domestic (US) Partner-Private Group Today's Date MM DD YYYY Workshop Partner Full Name (First Name and Last Name)(Required) Workshop Partner Organizaton(Required) Workshop Partner Organizaton Address(Required)Street, City, State Workshop Partner email(Required) What format is this workshop Virtual/Streaming (TalkTools will provide the virtual meeting platform) Virtual/Streaming (Workshop Partner will provide the virtual meeting platform) Live/In-Person Have you attended or hosted a TalkTools in-person workshop before? Yes No IN-PERSON OR VIRTUAL: Will you be attending each day of this workshop Yes No -- my colleague will be attending (see below) Workshop Course(s)select all courses you are hosting during this workshop 3-Part Treatment Plan for OPT Is it CAS? Or Something Else?: Differential Diagnosis and Treatment Feeding Foundations: A Kaleidoscope Model Feeding Therapy: A Sensory Motor Approach Functional Assessment and Treatment of TOTs (Tethered Oral Tissues) OPT: Assessment and Program Plan Development Taking Your Client with Autism from Non-Vocal to Verbal Unlocking the Superpowers of the Sensory System: Assessment and Treatment Select AllWorkshop Instructor(s)select all instructors presenting at your workshop Vanessa Anderson Smith Colette Ellis Robyn Merkel Walsh Lori Overland Monica Purdy Renee Roy Hill Heather Vukelich Rehab Zaytoun If Workshop Course is not listed above, please enter here If Instructor is not listed above, enter here Start Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920End Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Start Time(Required)each day Hours : Minutes AM PM AM/PM End Time(Required)each day Hours : Minutes AM PM AM/PM Workshop Partner has read the course description and timed agenda for this workshop(Required)Course Descriptions can be found on: https://talktools.com/pages/opt-course-descriptions (timed agendas link are included on each course description page) I have the course description and timed agenda for this workshop Workshop Private Group Fee(Required)Is TalkTools managing CEUs for this event on behalf of the Workshop Partner? Yes No CEU Filing FeeEstimated Number of Participants(Required)see Additional Terms belowPracticum/Hands-On Learning Supplies(Required)PLEASE REVIEW THE PRACTICUM LIST FOR THIS WORKSHOP - https://talktools.com/pages/live-workshop-practicum I have reviewed the practicum list This workshop is virtual; TalkTools will ship workshop supplies directly to each participant This workshop is in-person; TalkTools will ship workshop supplies to the shipping address provided in this agreement Workshop Venue/Location Address Point of Contact POC (Point of Contact) during the workshop Point of Contact (POC) cell Venue Meeting Room Requirements(Required) Workshop Partner will ensure meeting room requirements are met IN PERSON Feeding Therapy: A Sensory-Motor Approach -- Instructor SeatingA high bar stool is requested Yes -- we have a stool available No -- we don't have a stool available IN PERSON Feeding Therapy: A Sensory Motor Approach -- Live EvaluationsDo you have 2 candidates confirmed for the instructor to evaluate IN PERSON each workshop day? Yes Not at the time of signing this contract, but we will have this information before the workshop IN PERSON Feeding Therapy: Sensory Motor Approach -- If you have 2 live evaluations confirmed, provide the names, ages and diagnosisIf you do not have evaluations scheduled at the time of signing this agreement, provide a date when you will have evaluations scheduled IN-PERSON OPT: Assessment and Program Plan Development -- Live EvaluationsDo you have 2 candidates confirmed for the instructor to evaluate IN PERSON each workshop day? Yes No IN PERSON OPT: Assessment and Program Plan Development -- If you have 2 live evaluations confirmed, provide the names, ages and diagnosisIf you do not have evaluations scheduled at the time of signing this agreement, provide a date when you will have evaluations scheduled Ground Transportation will be provided(Required)this includes transportation to/from airport/hotel, hotel/workshop venue Yes We are unable to coordinate ground transportation for the Instructor Ground Transportation POC First Name Last Nameif this is the same person, enter "same as Workshop POC" below Ground Transportaton POC cell Shipping Address(Required)confirm where we sent all workshop supplies - street, city, state, zip
