Please provide the information that is requested in the following form. When you have completed all items, click on the SUBMIT button at the bottom of the list of items, then click on Return to EDS 643 Home Page at the end of the form.
Enter your full name as it appears on University records in the following form:
Enter your nickname or the name by which you are usually called:
Social Security Number: Gender: Female Male
Enter your local home address below:
Street: address: Apartment Number:
City: State: Zipcode:
If you are employed, what is your occupation?
Enter the address of your place of employment: Agency
Address 1:
Address 2:
Home Phone: WorkPhone:
E-mail address, if you have one:
Describe any information that we should know about in case of a health-related emergency:
Emergency contact person
Relationship to emergancy contact person:
Emergency phone number:
Are you taking this course for credit? Yes No
In which program are you enrolled? Masters Specialist Doctoral Post-Doctoral None
If you selected "None", describe your status:
If you are a student, what is your major? If you are a professional, your area of specialization:
If you are a student, who is your academic advisor?
I have (check all that apply)...
Used a Macintosh Computer
Never A few times Weekly Almost Daily
Never
A few times
Weekly
Almost Daily
Used an IBM (or compatible) computer
Set up a modem and configured its software
Set up a computer for Ethernet use
Used E-mail
Configured E-mail software
Surfed the Web
Configured Web browser software
Downloaded software from the Internet
Used on-line databases
Used search engines to find information on the WWW
Participated in "real time" chat on the WWW
Particpated in a MOO
Used/ participated in a newsgroup
Developed a Web page
Taught others to use telecommunication systems
Elaborate on any of the above experiences with telecommunication systems - particularly as they relate to special education and rehabilitation.
My computer of choice is: Macintosh IBM or compatible
Do you have a computer at home? Yes No
If you answered YES to the prior question, is it connected to modem? Yes No
What are your expectations for this course?
Any other related information your Instructor should know about you or your background?
Click this button when you have completed the above form:
To remove the data you entered, use the RESET button.
Revised June 9. 1997