Please complete and return this form if you would like your program listing considered for the Developmental Disabilities Website (www.ddhealthinfo.org).
Contact Information
Name: *
Sponsor/Organization: *
Address: *
City/State/Zip: *
Telephone: *
Fax:
E-Mail:
TITLE OF PROGRAM: *
PROGRAM DATES: *
LOCATION: *
TARGET AUDIENCE: *
REGISTRATION FEE (if applicable):
ESTIMATED ATTENDENCE *
# MDs/Dos # PAs # RNs # PTs/OTs
# Counselors # Other
COURSE DESCRIPTION and/or OBJECTIVES (Please type, cut and paste, or attach)
PROGRAM AGENDA and FACULTY LIST (Please type, cut and paste, or attach)
NUMBER OF CREDIT HOURS OFFERED # MDs/DOs # RNs # OTs # PTs
# BBS # Other URL ADDRESS (if applicable)
Once completed or print and send via FAX or mail to: University of California, San Diego 9500 Gilman Drive, 0617 La Jolla, California 92093-1217 Telephone - 858-434-3240 Fax - 858-554-7642 * Required Fields