DIR Floortime®

A Neurodevelopmental and Neurodiversity-Informed Approach to
Supporting Children and Adolescents on the Autism Spectrum:
Using DIR Floortime® to Promote Development

This course also meets the prerequisite requirements for professionals
to enter the DIR Floortime® Professional Certificate Program.

Wed/Th. May 17-18, 2023

Pricing

Standard Registration March 21, 2023 to May 17, 2023
$449.00/Participant for 1-4 Participants
$419.00/Participant for 5+ Participants

The Drop Down Menu at the bottom of the registration form will have the
correct pricing for the number of participants you are registering.

DIR Floortime® Registration Form

It is important that we have the participant's best contact information in case we need to reach them (especially outside of their business hours) for clarification and/or any last minute changes or information they may need. If other information is given we can not be responsible for lack of communication or expenses incurred as a result.

For a group rate to apply you must register all participants
on the same form and pay at the same time.

* Indicates required field

Name, Credentials, and Primary Address of each Participant: (Personal address is best. Please # and list each person if there are more than one registering together.) *

Primary Email Address of each Participant: (Personal email is best. Please # and list each person as above) *

Primary (personal) Phone Number of each Participant: (please # and list each person as above) *

Terms and Agreements (please check all 5 boxes) *

I agree to the Attendance Policy: I agree that I am attending a Live Conference in So. Portland, Maine on May 17-18, 2023 and that I must be present for the entire conference. No partial credit is given. Please make any travel arrangements to ensure that you do not arrive late or leave the conference early. I agree to the Payment Policy: All registration payments must be made in full or have an approved payment arrangement and/or issued purchase order with Coastal Education Services prior to the start of the conference in order to participate. I agree to the Cancellation Policy: I agree that I have read the Cancellation Policy in the Information Section under Policies completely and agree to the policy in full. If you have any questions please call Lisa Ottman at 207-286-5631. I agree as the Attendee that by registering and attending this course that Coastal Education Services and ICDL have access and permission to contact me as the attendee by phone, email and/or mail. This information will not be shared or sold to any outside organization, but will provide the attendee with access to information and resources related to this course and/or other pertinent information including Certificate of Attendance. At any time, I can opt out or unsubscribe by contacting either organization. Furthermore, if I am acting as an agent for the purpose of registering an attendee, I am agreeing to notify the attendee(s) of this agreement and am agreeing on their behalf, to receiving any and all communications by Coastal Education Services and/or ICDL. I agree that by checking this box I am verifying that I am the person registering for the course/activity and that by checking this box it will act as my online signature. All registrants will be contacted using the information in the registration form to confirm their registration and later receive other information to prepare for this conference. If an agent or one of the participants is completing the form for more than 1 person you acknowledge that you are signing on behalf of all participants that the information in the registration form is as accurate as you are aware of.

Submit

Registration Process:
1. Be sure to press "Submit" above to ensure we receive your registration form.
2. Now select your payment method below.

Credit Card

If Paying with a credit card please use the "Buy Now" PayPal button below to select the number of participants. Discounted Early Registration and prices for 5+ people are in the drop down menu

We use PayPal to process credit cards securely.
You will be redirected for the check-out process.

Checks or Purchase Orders

Complete the form below if Paying with Check or a Purchase Order and follow directions to process.
(Not necessary to complete if paying with a credit card)

How do you plan to pay if not by credit card?
Checks:
Payable to: Coastal Education Services and
Mail to: P.O. Box 3064, Kennebunkport, ME 04046
Please indicate the participant the payment is for.

Purchase Orders:
1. The SENDING BUSINESS MUST INITIATE a Purchase Order.
2. Purchase Orders are to be email with contact information to [email protected].
3. An invoice will be emailed to the contact person.

* Indicates required field

How will payment be made? *

Personal Check Business Check Purchase Order

Name of Conference Participant(s) *

Contact Person for Payment if different than the Participant *

First

Last

Contact Person's Email *

Contact Person's Phone Number *

Submit

Registration Process​:1. Be sure to press "Submit" above to ensure we receive your registration form.​2. Now select your payment method below.

Credit Card

If Paying with a credit card please use the "Buy Now" PayPal button below to select the number of participants. Discounted Early Registration and prices for 5+ people are in the drop down menuWe use PayPal to process credit cards securely. ​You will be redirected for the check-out process.​

Checks or Purchase Orders

​Complete the form below if ​Paying with ​Check or a Purchase Order and follow directions to process. (Not necessary to complete if paying with a credit card)

Registration Process:
1. Be sure to press "Submit" above to ensure we receive your registration form.
2. Now select your payment method below.

If Paying with a credit card please use the "Buy Now" PayPal button below to select the number of participants. Discounted Early Registration and prices for 5+ people are in the drop down menu

We use PayPal to process credit cards securely.
You will be redirected for the check-out process.

Complete the form below if Paying with Check or a Purchase Order and follow directions to process.
(Not necessary to complete if paying with a credit card)