Title:  _________________________________________________________________

Agency: _______________________________________________________________

Agency Address: ________________________________________________________

City: ___________________ State: _____ Zip: _______ Phone:  (____) _____-______

Length of time in present position: ________ years  ________ months

Course you are registering for: _____________________________________________

Reasons for attending this program:

   _____________________________________________________________________

   _____________________________________________________________________

Payment enclosed: ______ Yes  ______ No
    Please make checks, purchase orders and vouchers payable to RB House Assoc.
    All payments must be received prior to the registration date of the course.

Please check to ensure proper accommodations:
     ___ Wheelchair Accessibility

     ___ Audio Tapes

     ___ Assistive Listening Device

     ___ Interpreter Services( ____ASL____Oral____Deaf-Blind)

     ___ Large print

     ___ Braille

     ___ Handouts/materials on CD

     ___Other (describe) _______________________________________________