Application to Attend the ESDM Advanced Workshop

The ESDM Advanced Workshop (for professionals working with children with ASD, and degree qualified in the areas of Education, Allied Health, Psychology and Medicine) are scheduled 10-12 times each year. Applications are reviewed by an ESDM Certified Trainer prior to acceptance in the workshops.

Please read the ‘Pre-requisites for the ESDM Advanced Workshop’ below before completing this form.

Name of Service, Program, or Team
Name of Main Point of Contact (POC) Name of Main Point of Contact (POC) First Last
Address Address
Street Address City State Post Code Country
Name Name First Last
Email
Professional Background/Job Title
Highest Earned Degree & Certifications
Mailing Address Mailing Address
Street Address City State Post Code Country
Number of Direct Therapy/Treatment Hours you Provide Weekly
Preferred month of the year to attend the Advanced Workshop
Describe your core program/service details relative to young children diagnosed with an Autism Spectrum Disorder, or at risk of a diagnosis.
Why do you want to participate in this training program?
Pre-requisites for the ESDM Advanced Workshop
1. Each participant must purchase this manual: Early Start Denver Model for Young Children with Autism: Promoting Language, Learning, and Engagement (Sally J. Rogers and Geraldine Dawson)
2. Each participant must purchase The Early Start Denver Model Curriculum Checklist for Young Children with Autism (Sally J. Rogers and Geraldine Dawson).
  
  This is used to comprehensively assess the skills of toddlers and preschoolers with autism spectrum disorder across multiple developmental domains and to establish individualized teaching objectives. Administered on entry and reviewed every 12 weeks, it is an essential component of the intervention program described in the authoritative manual, Early Start Denver Model for Young Children with Autism. Sold in sets of 15 ready-to-use booklets.
3. Each participant must register for and complete the Early Start Denver Model - Introductory Workshop online via: UC Davis Extension or email cpeinfo@ucdavis.edu.
4. Please state either the date you completed your Early Start Denver Model-Introductory Workshop with UC Davis, or the date you have booked to do the workshop.
Workshop date Workshop date / DD / MM YYYY
Please attach your Certificate of Completion for the Early Start Denver Model-Introductory Workshop if you have it

Attach Files
1. Following these steps, each participant can then register for the ESDM Advanced Workshop, through Early Start - University of Wollongong, by submitting this form.
  
  This workshop is delivered remotely via a live zoom stream over 6 weeks of 3 hour sessions. With the support and guidance of your Trainer, you will work with a child with ASD, in your own service, and bring video footage of this work to each zoom session. Once you have registered and paid for your course, you will receive the Course Agenda and Workshop Handouts.
I have read and understand the ESDM Advanced Workshop pre-requisites above

I have read and understand the ESDM Advanced Workshop pre-requisites above Yes
Please note

By completing the ESDM Advanced Workshop you will not be certified in the ESDM, but you will have met two of the certification pre-requites: 1. Completion of the Online Introductory Workshop and 2. Completion of the Advanced Workshop. On completion of this workshop, you can apply to follow the Certification Steps required to become a Certified ESDM Therapist, under the supervision of your ESDM Certified Trainer. This is a necessary step to practice ESDM.
Acknowledgement

I acknowledge that, if selected for participation in the training workshop, you:
- Work regularly with 12-60 month-old children with ASD
- Have relevant qualifications such as a Bachelors Degree in: Early Childhood Education; Special Education; Speech and Language; Occupational Therapy; Physiotherapy or Applied Behaviour Analysis or medical degrees.
- Have completed or are enrolled in the Online ESDM Introductory Workshop through UC Davis Extension, within the last 3 years.
- Have read and will bring a copy of the manual, Early Start Denver Model for Young Children with Autism: promoting language, learning, and engagement, and the Early Start Denver Model Curriculum Checklist for Young Children with Autism (both by Sally J. Rogers and Geraldine Dawson). These resources are sold separately to this workshop.
- Have reliable internet connection to participate in each zoom session
- Full payment is due prior to workshop start date. No refunds will be issued for cancellations.
Acknowledgement

Acknowledgement Yes
Data collection statement

The information you provide on this form will be used by the Early Start Autism Clinic Team at the University of Wollongong to register your interest in the ESDM Advanced Workshop. It will be stored on a secure database and accessed by the ESDM Training Coordinator.

Application to Attend the ESDM Advanced Workshop

Application to Attend the ESDM Advanced Workshop

Pre-requisites for the ESDM Advanced Workshop

Please note

Acknowledgement

Data collection statement