* Name:

• First (given name)
• Last (surname / family name)

* Address:

• Street
• City
• State/Province
• Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, Democratic Republic of Cook Islands Costa Rica Cˆte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao, People's Democratic Republic of Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Phillippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago United States Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Vietnam Virgin Islands, British Virgin Islands, US Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country
• Postal Code/Other

* Phone (include country code): -

* Mobile number: -

Time Zone: (UTC -12:00) Baker/Howland Island (UTC -11:00) Samoa Time Zone, Niue (UTC -10:00) Hawaii-Aleutian Standard Time, Cook Islands, Tahiti (UTC -9:30) Marquesas Islands (UTC -9:00) Alaska Standard Time, Gambier Islands (UTC -8:00) Pacific Standard Time, Clipperton Island (UTC -7:00) Mountain Standard Time (UTC -6:00) Central Standard Time (UTC -5:00) Eastern Standard Time, Western Caribbean Standard Time (UTC -4:30) Venezuelan Standard Time (UTC -4:00) Atlantic Standard Time, Eastern Caribbean Standard Time (UTC -3:30) Newfoundland Standard Time (UTC -3:00) Argentina, Brazil, French Guiana, Uruguay (UTC -2:00) South Georgia/South Sandwich Islands (UTC -1:00) Azores, Cape Verde Islands (UTC) Greenwich Mean Time, Western European Time (UTC +1:00) Central European Time, West Africa Time (UTC +2:00) Central Africa Time, Eastern European Time, Kaliningrad Time (UTC +3:00) Moscow Time, East Africa Time (UTC +3:30) Iran Standard Time (UTC +4:00) Azerbaijan Standard Time, Samara Time (UTC +4:30) Afghanistan (UTC +5:00) Pakistan Standard Time, Yekaterinburg Time (UTC +5:30) Indian Standard Time, Sri Lanka Time (UTC +5:45) Nepal Time (UTC +6:00) Bangladesh Standard Time, Bhutan Time, Omsk Time (UTC +6:30) Cocos Islands, Myanmar (UTC +7:00) Krasnoyarsk Time, Cambodia, Laos, Thailand, Vietnam (UTC +8:00) Australian Western Standard Time, Beijing Time, Irkutsk Time (UTC +8:45) Australian Central Western Standard Time (UTC +9:00) Japan Standard Time, Korea Standard Time, Yakutsk Time (UTC +9:30) Australian Central Standard Time (UTC +10:00) Australian Eastern Standard Time, Vladivostok Time (UTC +10:30) Lord Howe Island (UTC +11:00) Magadan Time, Solomon Islands, Vanuatu (UTC +11:30) Norfolk Island (UTC +12:00) Fiji, Gilbert Islands, Kamchatka Time, New Zealand Standard Time (UTC +12:45) Chatham Islands Standard Time (UTC +13:00) Phoenix Islands Time, Tonga (UTC +14:00) Line Islands

* Email address:

Secondary Email address:

A Skype account is required for video conferencing, in case we need to do an interview via this format.

Please list your Skype account name:

(If you do not have a Skype account, this is a free downloadable program that can be found at www.skype.com)

High School (Secondary/Upper School)

* School Name:

* City/State:

If so, what year?:

College/University

School Name:

City/State:

Degree:

Years Attended:

Major:

Graduate School

School Name:

City/State:

Degree:

Years Attended:

Major:

Business, Vocational or other

School Name:

City/State:

Degree:

Years Attended:

Major:

* Current Employer/Organization:

* Profession/Role within Organization: (Please select) Teacher Director Therapist Parent of Special Needs Child Medical Professional Other

* Supervisor's Name:

Employer's Address:

• Street
• City
• State/Province
• Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, Democratic Republic of Cook Islands Costa Rica Cˆte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao, People's Democratic Republic of Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Phillippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago United States Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Vietnam Virgin Islands, British Virgin Islands, US Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country
• Postal Code/Other

Phone: -

Email address:

Website address:

Type of organization: (Check all that apply)

• School
• Parent Training Center
• Therapy Center
• For-Profit
• Not-for-Profit
• Orphanage
• College / University
• Professional Association
• Religious-based
• Hospital
• Psychiatric Clinic / Facility
• Residential Facility
• Private
• Government-funded program
• Non-Governmental Organization (NGO)
• Other: (please list)

* Languages Spoken:

* Nationality:

* With what types of children do you primarily work? (Check all that apply)

• Autism
• Asperger Syndrome
• Cerebral Palsy
• Down Syndrome
• Visual Impairments
• Deaf/Hard of Hearing
• Deaf and Blind
• Learning Disability
• Behavior Disorder
• Other Health Impairment
• Pervasive Developmental Disability (PDD-NOS)
• Multiple Disorders
• Other: (please list)

* What is the age range of the children that you serve?

• 0 - 4 yrs
• 5 - 10 yrs
• 6 - 13 yrs
• 14 - 22 yrs
• 22+ yrs
• I mostly work with adults over the age of 22.

How many children (under age 22) do you work with?

Please list the names of three references. References must have a working phone number or email address. Please include a customer/client as one of your references, as well as at least one executive officer, director or board member of your current employer/organization.

* Name:

* Organization:

* City/Country:

Website: (leave blank only if there is no website)

* Phone: -

Email:

* Relationship:

* Years Known:

* Name:

* Organization:

City/Country:

Website:

Phone: -

Email:

Relationship:

Years Known:

* Name:

* Organization:

City/Country:

Website:

Phone: -

Email:

Relationship:

Years Known:

* 1. How do the children you work with primarily communicate? (Please check all that apply)

• Verbally
• Sign Language
• Uses Pictures/Symbols/Objects
• Speech Generation System
• Points/Pulls You to the Item
• Other (please list):

* 2. Do the children you serve have behavioral difficulties?

• Yes
• No
• Don't Know

If yes, how frequently do you work with children who have behavioral difficulties?

• Daily
• 1-2 times a week
• A few times a month
• Rarely (just a few times a year)

If yes, which of the following have been used to address the behavior difficulties?

• Functional Behavior Assessment
• Behavior Intervention Plan
• Positive Behavioral Supports
• None of the Above

Has this plan/intervention been successful?

• Completely
• Somewhat
• No
• Don't Know

3. Do the children you serve have the help and support necessary to be successful in their home and community?

• Yes
• No
• Don't Know

If no, what is the main concern?

The next section is to help us identify appropriate trainings for you. Your answers will not affect whether you are selected, it's simply to help us know how to focus the trainings.

* 4. Tell us briefly what you believe is the cause of autism:

* 5. Are there any known cures for autism?

* 6. What are evidenced-based interventions? (please give examples)

* 7. Identify the main principles of Applied Behavioral Analysis (ABA):

* 8. What are the main concerns in your country regarding children with special needs? In what areas do people in your country need to be educated or trained?

* 9. Please indicate in what areas you would like additional training (if selected, this will be used to schedule your training time while here):

Communication

• Functional Communication Training
• Assistive Technology Introduction

Training / Professional Development in Special Education

• Autism Spectrum Disorders Overview
• Introduction to Applied Behavioral Analysis (ABA)
• Basic Behavioral Psychology Training
• Functional Behavioral Assessment
• Positive Behavioral Supports
• Toilet Training Programs
• Designing supports for the family
• Social Skills Training
• Meal Plans & Eating Procedures
• Service Coordination (finding available resources for families)
• What is Evidence-Based Practice? (training on how to determine what interventions are research-based and empirically validated)

Interactive Classroom or Residential Training

• Academics/Pre-Academics
• Classroom Arrangement/Design
• Recreation/Leisure Skills
• Functional Daily Living Skills
• Student Organizational Skills
• Structured Teaching
• Community-Based Instruction
• Vocational Training Program (Sheltered Workshop Program)
• Group Activities: Cooking, Handwriting, Interpersonal Skills, etc
• Classroom observations and assisted interactions with our students/staff
• Residential (group-home) observations and assisted interactions with our students/staff

Training / Professional Development in Management, Administration and Operation

• Leadership Development
• Administrative/Supervisory Skills
• Development, grant writing, fundraising
• Marketing/Communications
• Strategic Planning
• Budgeting Planning

Other

• Community Outreach Programs
• Out-patient Therapy Observations
• Other (please list):

* In addition to the trainings checked above, all participants will tour other local organizations that serve people with disabilities.

* Briefly explain why you are interested in the Heartspring World Reach Training Solutions program:

Please provide any other information that will allow us to best suit your needs during your visit:

If you are affiliated with an organization, please provide any brochures, flyers, pamphlets or images that show your organization's mission and work.

If you are requesting financial assistance, please upload your organization's Annual Report, Annual Budget and proof of Non-Profit or NGO status.