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APPLICATION FOR LEVEL III DISC CERTIFICATION
Name: _______________________________________________________
Agency: _______________________________________________________
Address: ______________________________________________________
______________________________________________________________
Postal Code: ___________________
Telephone: (____)___________________
Education: ____________________________________________________
Current Position and Duties: ____________________________________________________________
___________________________________________________________________________________
Related Experience: __________________________________________________________________
___________________________________________________________________________________
Current Supervisor: ____________________________________________
Telephone: (______)______________
Attach Work Sample : (Include one DISC Record Form with all identifying information
deleted except for the child's age; all 3 Summary sheets; brief summary
report re: child's history, observation during screening session, interpretation
of results, referrals or programming strategies.) Please also include a
video of the administration of the DISC corresponding to your work sample
along with a video critique. A Report Outline for the DISC and Video Critique
form are available on the DISC website.
Total # of DISC Screenings Completed to Date: ______ A minimum of 25 DISC
administrations is advised before submitting a Level III work sample.
Have you attended a Level III DISC Training Workshop? No: ___ Yes: ___
Date: ____________
If No, please enclose a cheque for ($50. + $6.50 HST) $56.50 for marking.
Please return this application and work sample to: Marian Mainland
Mainland Consulting Inc.
4 Danube Drive,
Heidelberg, Ontario
NOB 1YO, Canada
Phone: (519) 699-5429 Fax: (519) 699-4890
Email: mmainland@rogers.com
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