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Be sure your email address is filled in or the form will not submit

ESSE Registration Form
In the event that payment is by purchase order, both the application
and the Purchase Order must be received together. (See note bottom of page)
A separate application is needed for each individual.
Cost is $300.00 for the full evaluation
$225.00 for the Expressive only
$75.00 for the Receptive only when administered at a SEE Center determined location.
For other locations, contact the SEE Center for cost determination.

Session Location: Date:

Name: Address: Type of ESSE:

City:   State/Province:   Zip/Postal Code:

Phone: Home: Work:
Email Address:

Address to which results are to be sent if different from above:

Employed by (School District):  
At what level? (check all that apply) Elementary Middle School High School

Total Years Interpreting? Sign Language Mode Used:

ITP Program graduate? Yes No

If Yes, 2 year or 4 year program? Other Program? Yes What Program?
If No, brief comment about where you learned signs:

Have you previously taken the E.S.S.E.? Yes No 

If Yes, Location:
Level: Elementary Middle School High School 

Payment must be included with application. For applications sent with Purchase Order, full payment must be made prior to the date of the assessment. For payment by check, email this reservation form to secure your place and mail the check to:

S.E.E. Center for the Advancement of Deaf Children
P.O. Box 1181
Los Alamitos, California 90720-1181

Check must be received 4 business days from reciept of email reservation or your place will be released.

I am paying by: Purchase Order Number: (See note at bottom)
Type of Credit Card:

Credit Card Number:

Credit Card Expiration Date:

Name on Credit Card:

Billing Address of Credit Card:

 Clear or Reset this form: Submit via email: (click once)

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When using an Institutional Purchase Order, hard copy of the P.O. must accompany the
registration and must be for the full amount of registration. Please print this form and
either FAX or mail the completed form with the P.O. to:

S.E.E. Center for the Advancement of Deaf Children
P.O. Box 1181
Los Alamitos, California 90720-1181

OR FAX to: (562) 795-6614