Please type

or print.

Florida Department of Education

Speech/Language Weekends with the Experts

Orlando, Florida

Registration Deadline: December 5, 2003

Name of School District: _____________________________________________________________________________________

School District Address: _____________________________________________________________________________________

Name of District Speech/Language Coordinator: __________________________________________________________________

Coordinator Phone Number:___________________________________ Coordinator Email:_______________________________

(Required)

Name of Person Completing Form: __________________________________________ Phone: ___________________________

(If different from above)

Do not

register

more than the following number of participants per district for each workshop. If there is space available,

additional therapists may be able to attend this workshop. Please list additional therapists on a separate sheet of paper.

Number of participants:

Counties:

8 per very-large size district……. Dade, Broward, Hillsborough, Palm Beach, Orange, Duval, Pinellas

6 per large size district………….. Polk, Brevard, Volusia, Seminole, Lee, Pasco, Escambia

4 per medium size district………. Marion, Manatee, Sarasota, Leon, Collier, Okaloosa, Osceola, Alachua, St. Lucie,

Lake, Clay, Bay, Santa Rosa, St. Johns

2 per med-small size district……Charlotte, Hernando, Martin, Citrus, Indian River, Putnam, Highlands, Nassau,

Monroe, Columbia, Gadsden, Jackson, Hendry

1 per small size district…………..Okeechobee, Levy, Flagler, Sumter, Walton, Suwannee, Hardee, Baker, DeSoto, Wakulla,

Bradford, Taylor, Holmes, Madison, Washington, Gilchrist, Dixie, Union, Gulf,

Calhoun, Hamilton, Jefferson, Franklin, Liberty, Glades, Lafayette

�? �?

Yes

No

The District Speech/Language Coordinator will attend the January 10-11, 2004 Weekend with the Experts:

Participant's Name

Email Address (Required)

1.

2.

3.

4.

5.

6.

7.

8.

Please mail or fax to:

CSPD Project, University of South Florida St. Petersburg

th

Avenue South, SVB 108

St. Petersburg, FL 33701-5016