ESSE Registration Form

Please complete the form below and follow submission instructions at the bottom of this page.
In the event that payment is by purchase order, both the application and the purchase order must be received together (see note at bottom of page). A separate application is needed for each individual.

Cost:
$300.00 for full evaluation
$225.00 for Expressive only
$ 75.00 for Receptive only

**If evaluation is not taken at a SEE Center determined location--cost may vary. Please contact SEE Center for cost determination.

* Session Location

* Session Date

* Type of ESSE

* First Name

* Last Name

* Address 1

Address 2

* City

* State/Province

* Postal Code

Business Phone

* Home Phone

* Email Address

* Employed by (School District)

* Total Years Interpreting?

* Sign Language Mode Used

* ITP Program Graduate?

If no, brief comment about where you learned signs:

If yes, 2 year or 4 year program?

Other program?

Yes

Name of program?

* Have you taken the ESSE previously?

If yes, which location?

Level:

Payment must be included with your application. For applications sent with a purchase order, full payment must be made prior to the date of the assessment. Hard copy of the PO must accompany the registration and must be for the full amount of the registration cost. For payment by check, e-mail this reservation form to secure your place and mail the check to:

S.E.E. Center for the Advancement of Deaf Children
P.O. Box 1181
Los Alamitos, CA 90720-1181

Checks must be received 4 business days from reciept of e-mail reservation or your place will be released.

* I am paying by:

Name on Card

Credit Card Type

Credit Card Number

Expiration Date (mm/yy)

Credit Card Billing Address:

* Indicates Response Required


Powered by FormSite.com