Georgia PINES Registration Intent Form
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NEW APPLICATION
Contact Information:

      First Name
      Last Name
           Address
                  City State Zip County
    Home Phone Home Phone TDD
Work Phone Work Phone TDD
       Cell Phone     Cell Phone TDD Email
         Birthdate

Area of Interest:SKIHI INSITE

Current Employer:

Current Employer
Employer Address
       Employer City Employer State Employer Zip
     Employer Email
Do you plan to remain in your current position for next year Y/N?
If no, explain.

Teacher Certification Level    Teacher Certification Type 

Educational Background:

    University     Dates Attended     Degree         Major     Certified In      GPA

Employment History:

Special Education Experience:    Resource Itinerant Self Contained Other

    Employer           Position       To/From       Grade Level

1. What courses and/or experiences have you had in early childhood/family dynamics?

2. What courses and/or experiences have you had with children who have hearing loss?
Please include ages of children, degree and type(s) of hearing loss, hearing aids, cochlear implants, FM systems, etc.


3. What courses and/or experiences have you had with children who have visual impairment?
Please include years of experience, ages of children, degree and type(s) of sensory impairment, assessments used, etc.


4. What courses and/or experience have you had with deafblindness?
Please include years of experience, ages of children, degree and type(s) of visual impairment, assessments used, etc.


5. Please rate your sign language skills:

Additional comments:

6. What courses or workshops have you had regarding listening skill development?

7. Describe any experience/training with Braille

8. What experiences have you had with children with multiple disabilities?

Mild Moderate Severe-Profound

Explain:

9. Have you ever used a preschool curriculum?

If yes, which curriculum have you used?

10. Do you have experience in home intervention?

Please describe:

11. What experience do you have working with parents?

12. If contracted, which counties are you able to serve?

13. In what languages are you proficient?

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