KY-SPIN's Bridging the Gap in Special Education

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• Address 2:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Phone:
• * County in KY

The trainings are funded in part through a grant from Wellcare of Kentucky.

• *

  What health insurance carrier do you have? (Note: KY-SPIN will not ask for or bill your insurance, this is for WellCare's informational purposes to better assist families)

  • WellCare (please complete the next question)
  • Anthem
  • Aetna
  • Passport Molina
  • United Health
  • Humana
  • Other
  • I do not have health insurance
• To help WellCare serve the needs of their clients, please share WellCare member names and dates of birth below. (Note: KY-SPIN will not ask for or bill your insurance, this is for WellCare's informational purposes to better assist families)
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• *

  I'm registering to attend

  • January 11, 2024 at 9am – 5pm (ET) Virtually through Zoom
  • January 27, 2024 at 9am – 5pm (ET) Virtually through Zoom

• *

  Chose the options that best describes you: I learn best when I

  • See Graphics/Pictures
  • Hear it
  • Read it
  • Write it
  • Have examples
  • Other (Complete the next question please)
• I chose Other above, please explain how you learn best

• Ethnic Group (Optional & Confidential)

  • African American
  • Asian
  • Caucasian/White
  • Hispanic
  • Native American
  • Other

• Does your child have a disability? (Optional and Confidential)

  • Yes
  • No
  • I suspect they do
• If so, what disability? (Optional and Confidential)

• Do you have a disability? (Optional and Confidential)

  • Yes
  • No
  • I suspect I do
• If so, what disability? (Optional and Confidential)
• *

  I am a (check all that apply):

  • Person with a Disability
  • Parent/Guardian
  • Surrogate/Foster Parent
  • Grandparent
  • Sibling
  • Other Family Member
  • Educator
  • Peer Support Specialist
  • Provider
  • Other (please indicate your role below)
• I answered "Other" above, please indicate your role in attending the training:
• * Do you need disability related accommodations to participate? If yes, please explain: Note: Reasonable accommodations will be made given ample opportunity.

• I would rate my understanding of the training topics before the training as (check one):

  • Expert
  • Knowledgeable
  • I know some
  • Unfamiliar