IRLEN DYSLEXIA CENTRE For Reading and Perceptual Disorders ------------------------------------------------- GLORIA J. THOMAS IDII B.Ed D.Tch MAAIC Regional Director: Victoria, Tasmania and ACT. DARREN G. THOMAS B.Ed MAAIC Regional Director: Sydney.

APPLICATION TO TRAIN AS AN IRLEN SCREENER

Name………………………………………………………………………………….

Address……………………………………………………………………………….

………………………………………………………………………………………...

Phone………………………………………….Fax………………………………….

Email………………………………………………………………………………….

Date of Birth………………………………………………………………………….

Qualifications…………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

Teaching Experience…………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

Other Relevant Information…………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

Signature………………………………………Date…………………………………