Biosketch/Professional Profile Form

Massachusetts Early Intervention COMPETENCY EDUCATION CREDIT ASSIGNMENT APPLICATION

Instructor Profile Form

Instructor Name:

Educational Offering: Educational Background College or University Degree Date Rec’d

Early Intervention Experience Massachusetts CEIS #: Other certificates/licenses

Supervision and Training Experience (including team teaching and mentoring)

Qualifications (experience and training) for presenting this topic:

Other Related Experience (e.g., parent of a child with special needs, community service, volunteer work, etc)

Competency Education Credit -- Application/Instructor Profile Page 1 of 1 Early Intervention Training Center, 2005