New TBI Member Form 2016-2017
Thank you for your interest in improving services for students with Traumatic Brain Injury. By becoming a member of the Oregon TBI Educational Consulting Team, you are joining a community focused on supporting students with TBI in Oregon. For all new members of the TBI Team, we ask for an initial commitment of two years following the twelve month training period. Most often, the first year focuses predominantly on training activities, your current caseload, and building a relationship with the TBI Team in your region. Membership of the Oregon TBI Team is limited to Oregon Dept of Education and school district employees only. If you have questions, please contact Melissa McCart at mccart@uoregon.edu.
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First Name
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Last Name
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Job Title
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Licensure/Certification
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What region are you in?
District/Organization
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Cell Phone
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Work Phone
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Email Address
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Mailing Address (street, city, zip code)
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Have you ever worked with a student with TBI?
Have you attended any workshops or trainings related to TBI?
If yes, please give a brief description of the trainings that you have attended.
Your answer
Would you be willing to be contacted by other members of the TBI Team to share specialized knowledge pertaining to a case?
Supervisor's Name
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Supervisor's Email Address
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Supervisor's District/Organization
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Do you have your supervisor's approval to participate on the TBI Team? (An email will be sent to your supervisor upon completion of this registration form.)
Have you spoken to your regional liaison?
Do you give permission for CBIRT to publish photos of you in the TBI Team newsletter, websites or its social media pages? Checking yes below indicates your consent to publish photos of you from TBI Team events.
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