UA SP26- School Registration- Duval County

Name of School/Resource Provider*
PrivateCharterHomeschoolOnline LearningPPECTherapy Center (not a school)Other
High functioning (grade-level or near grade-level with supports)Moderate functioning (may require modified curriculum and supports)Low functioning (requires significant academic, behavioral, and/or daily-living supports)We serve students across all functioning levels
Name of Contact Person*

First NameLast Name
Title*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
School/Resource Website*
Brief Description of Your School/Company*
YesNoAfter The FairNot Interested
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Attending Representative #1*

First NameLast Name
Representative Email*
example@example.com
Attending Representative #2

First NameLast Name
Representative Email
example@example.com
Early Learning (Preschool)Elementary School (K-5)Middle School (6-8)High School (9-12)N/A
Academic/College PrepTherapeutic/Sensory IntegrationBehavioral/ABA-BasedLife Skills/VocationalArts/CreativeFaith-Based
Age Min.*
Age Max.*
AnaphylaxisAutism spectrum disorderCerebral PalsyDown syndromeEmotional or a behavioral disabilityHearing impairment, including deafnessHospital or homeboundIdentification as dual sensory impairedIntellectual disabilityLanguage impairmentMuscular dystrophyOrthopedic impairmentPhelan-McDermid syndromePrader-Willi syndromeSpecific learning disabilitySpeech impairmentSpina bifidaTraumatic brain injuryVisual impairment, including blindnessWilliams syndrome
ABA ProviderSpeech Language Pathology (SLP)Occupational Therapy (OT)Physical Therapy (PT)Tutoring ServicesSocial Skills GroupBehavioral ServicesDiagnostic/Assessment CenterOther
Summer ProgramBefore School CareAfter School CareEnrichment ProgramsExtended School Year (ESY)None
Tuition Range*
Do you accept the FES-UA or FES-EO Scholarship?*
School Partner Agreement:

By submitting this form, I consent and acknowledge the terms and conditions of the organization (UA School Fair). I confirm that I have been authorized to represent the company in submitting the information above.
Signature*

Clear
Date*

MonthDayYear
Date

BOOTH REGISTRATION

Booth Registration Fee

includes 2 representatives

$295.00

Additional Representative Fee: $15

(max 1 additional)

$15.00 Quantity

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty: