Learner Registration Form

Birmingham Employs Neurodiversity Expo Registration
Thank you for taking the time to register your student for the Birmingham Employs Neurodiversity Career and Internship Expo taking place on November 19, 9am-12pm.

Participants should arrive by 8:30am to check-in and attend the opening keynote at 9am. The self-guided expo will follow from 10am-12pm. Participants may take the full two hour window to meet with exhibitors.

Please complete the following registration form on behalf of the student, as your official recommendation, to confirm the Learner's readiness to pursue career-connected learning opportunities.

Questions may be sent to Kristen Jackson at kjackson@springvalleyschool.org.
Learner's Name*

First NameLast Name
Number of guests attending the event with this student*
Recommender's Name*

First NameLast Name
Recommender's Organization and Title*
Recommender's E-mail*
example@example.com
Learner's E-mail
example@example.com
Grade in which Learner is currently enrolled*
School in which Learner is currently enrolled*
Current Age of Learner (16-22 for internship opportunities / 14-and-up for career exploration)*
Participant's Gender, for data collection purposes
Participant's Ethnicity, for data collection purposes
If applicable, is this Learner currently earning a college degree? Please specify: Associate, Bachelor's, or Post-Graduate*
This student is considered neurodiverse because:*
For accommodations purposes, this student has the following learning difference(s):

DyslexiaDyscalculiaDysgraphiaADHDHigh functioning AutismVisual ProcessingAuditory ProcessingDyspraxiaDysphasia
Learner's Areas of Interests, including current school subjects and future career-related industries*
This student agrees to participating in post-event surveys:*

YesNo
This student is interested in pursuing an internship for the upcoming Spring/Summer semester (4-6 hours/week):*

YesNo
This student has the ability to effectively communicate:*

YesNo
This student has the ability to self regulate:*

YesNo
This student has the ability to comprehend safety protocols:*

YesNo
This student has a current GPA of 2.0 or above:*

YesNo
This student has the ability to obtain transportation to the internship, if applicable:*

YesNo
Please Note: The purpose of the Birmingham Employs Neurodiversity Expo is to provide a designated space for Birmingham's neurodiverse learners and business community to equally engage in career-connected learning opportunities. Following this event, learners have the opportunity to apply for internships and businesses have the opportunity to more effectively attract, employ, and support neurodiverse talent.

Internships are not guaranteed for every participating learner, as these placements are determined by the application process and capacity of each participating business. The event hosts, nor advisors, match learners to a business. Rather, advisors will simply serve as a guide to the learner in the application process. Additionally, internships are unpaid unless otherwise decided by the employer.
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Birmingham Employs Neurodiversity Expo Registration