Assistive Technology Applications Certificate Program Application

Thank you for your interest in the Assistive Technology Applications Certificate Program (ATACP). The ATACP is designed to provide a practical approach to the applications of Assistive Technology in meeting the needs of individuals with various disabilities in many settings.

The following form contains approximately 17 required fields and 18 optional fields. We recommend reviewing the entire form prior to filling it out, typing longer answers into Notepad, and copying/pasting them into the form.

Training You Are Interested In:

Personal Information

First Name

Middle Name

Last Name

Date of Birth--

Street Address

City

State

Zip Code

Country

Phone

Disability Accommodations

Other Accommodation

Education (please list the highest degree or schooling completed)

Most Recent Institution

Name of Most Recent Institution

Field/Degree

Year graduated

Other Institution

Name of Other Institution

Field/Degree

Year graduated

Experience (please list all relevant employment, volunteer and/or other activities)

Active/most recent position

Most Recent Position/Title

Employer

Dates from-

to-

Other Experience

Position/Title

Employer

Dates from-

to-

Other Experience

Position/Title

Employer

Dates from-

to-

Why are you interested in the ATACP Training?

Describe your work or experience with people with disabilities.

List any experience you may have working with assistive technologies.

What are you hoping to learn from ATACP?

How did you learn about the CSUN ATACP and Center on Disabilities? (required)

Other

Have you previously attended CSUN (required)

Have you previously attended CSUN or the Tseng College of Extended Learning at CSUN?YesNo

If yes, please provide your CSUN student ID. (Optional)

Yes, I would like to learn more about the online masters in Assistive Technology and Human Services (M.S.)

* Refunds can be issued only if a request for cancellation is received in writing 30 days prior to live training date and on-line user name and password has not been used (less the $50.00 cancellation processing fee).