Listen to Me! International Workshops Registration

Listen to Me!

International Workshops Registration

First Name*

Last Name*

Professional Degree

Ex: AuD, MD, MBBS

Email*

Country*

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Institution*

Place of work

English Proficiency Level*

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Do you require an interpreter?

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What language?

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What is your level of experience in utilizing a Listening & Spoken Language / Auditory Verbal Therapy approach?*

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Will you need assistance with using Zoom for our workshops?*

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Will you be able to attend all 8 workshops?*

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PHOTOGRAPHY/RELEASE AGREEMENT

Sponsor: Baker Institute for Children with Hearing Loss

I understand this workshop will be on Zoom and will be recorded. By participating in this workshop, I acknowledge that my likeness, image, name, and voice may be captured on the recording as a result of my participation in the learning. I authorize the Sponsor to use my likeness, image, name, and voice as a participant in the workshop for the purposes of the Sponsor. The Sponsor may use and authorize others to use all or parts of the photographs. Sponsor, its successors, and assigns shall own all rights, title, and interest, including copyright, in and to the Event, including the photographs, to be used and disposed of without limitation as Sponsor shall in its sole discretion determine.

Please type your full name as consent*

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