EmailMe Form - GEORGE

Demographics

Name *

First Last

Email *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

How would you describe your race? *

Are you of Hispanic, Latino or Spanish origin? *

Yes

No

Do you fluently speak a language other than English? *

Yes

No

If you speak another language please specify

Motivation

Early Intervention: This term is used here to describe state programs of services and supports designed to help eligible infants and toddlers with developmental delays or disabilities and their families. Early intervention programs are available in every state and coordinated by the state's lead agency and employ teams of service providers across disciplines and include (but is not limited to) service coordinators, teachers, occupational therapists, physical therapists and speech-language pathologists.

How did you find out about Graduate Education Of Related Service Providers at Georgetown and George Washington Universities in Early Intervention (GEORGE) (pick all that apply) *

Tell us why you are interested in serving infants, toddlers, and young children with disabilities or developmental delay and their families in early intervention?

Please rank the reasons why you have chosen to participate in the GEORGE program

To help get a job in early intervention/serving children *

To help get a different job *

To help with credentials to be an early intervention provider in the District of Columbia *

To help advance in my current job *

To become better informed about early intervention *

To provide personal enjoyment and enrichment *

To discuss early intervention issues with experts and colleagues *

To be more effective in helping young children and their families *

To obtain continuing education credit *

To learn from and along with experienced child serving providers *

To participate in an interdisciplinary/inter-professional clinical learning experience *

Are there other reasons why you have chosen to participate? *

Please provide a brief summary of your overall interest in early intervention as a career with a professional goals statement (400 words or less) *

Additional Application Requirements

In addition to this application, please submit:

One letter of recommendation from a current or recent employer, clinical instructor, preceptor or other clinical supervisor commenting on your professional skills *

One letter of recommendation from a current instructor/faculty member in your program commenting on your ability to participate in additional course work including your ability to organize and manage additional academic work including online, in-person, and practicum experiences (500 words or less) *

Your current curriculum vitae (resume) *

A transcript from your professional degree granting program (can be unofficial) *