Name: RTSC – Gloucester Orientation
Start: 2019-08-01T16:00:00-04:00
End: 2019-08-01T19:00:00-04:00

Application Date*

Contact Information

Name*

Prefix First Last

Mailing Address

Street Address City State / Province / Region ZIP / Postal Code Country

Address Type

Home
Work

Phone*

Phone Type

Additional Phone Number (optional)

Phone number type

Fax

Email*

Enter Email Confirm Email

Are you a Visiting Resource applying to be a Special Education Surrogate Parent for a specific child?

No
Yes (not common)

Please enter the child's initials here:

The SESP Program will be contacting you to facilitate the processing of your CORI.

Volunteer Information

Employer

How would you best describe your role/profession? (Select all that apply)

Parent
Educator
Educational Administrator
Attorney
Clinician
Other

Please indicate your ethnicity:

This information is requested for the determination the representative sample of volunteers for generalization purposes.

Caucasian/White
Hispanic/Latino
African American/Black
Native American/American Indian/Alaskan Native
Asian/Pacific Islander
Undisclosed

Have you registered for a mandatory orientation training?*

Yes (If yes, please enter the Training date and location below.)
No (If no, please register for one at: https://fcsn.org/rtsc/events-calendar/

Orientation Training Date

Orientation Training Location

All orientations are currently being hosted virtually.

How did you hear about the SESP program?*

*Please Specify

Are you or your spouse employed by any public or private agency or agencies (including school systems) involved with the care or education of children?*

Yes
No

*If yes, please describe below.

Do you speak any languages other than English?*

Yes
No

*Please Specify

Are you the parent or relative of a child with special needs?*

Yes
No

*Please Specify

Would you prefer a match with a child in a particular age group? Any age*

Select All
3-6
7-12
13-16
17-22
Not sure

Please check the type(s) of disabilities in which you have the most interest or experience:*

Would you be willing to serve as an SESP for more than one child at a time?*

Select All
Yes
No
Not sure

Please list the names of cities/towns where you are willing to volunteer:*

There are certain areas of the state where there is consistently a high need for SESPs. Please include if you are willing to help a child in need in any of the following towns:

Please tell us about your background and/or interest in special education.*

Is there any other information about yourself that you want to provide for this application?

Reference 1:*

Full name, email address and phone number

Reference 2:*

Full name, email address and phone number

Reference 3:

Full name, email address and phone number

Special Notice: If you do not receive a confirmation email after submitting your form, your application was not received. Please attempt to resubmit it using another browser or fill in and save the Paper Application using the link at the top of the page. You can then mail or email the form to us as indicated.

Volunteer Agreement*

I understand the information provided below.

In order to serve as a Special Education Surrogate Parent, I understand that I will also be required to consent to a Criminal Offender Record Information (CORI) check that must be repeated every three years. I understand that my application does not guarantee my appointment as a volunteer Special Education Surrogate Parent. I also understand that I must receive training, as requested, to be appointed as a Special Education Surrogate Parent. If appointed, I will protect the confidentiality of all information regarding students I represent in special education matters.

RTSC – Gloucester Orientation

August 1, 2019 @ 4:00 pm - 7:00 pm

Register for Orientation

Contact Information

Volunteer Information

Details

Your Support
Moves Dreams
Forward

RTSC – Gloucester Orientation

August 1, 2019 @ 4:00 pm - 7:00 pm

Register for Orientation

Contact Information

Volunteer Information

Details

Your Support Moves Dreams Forward

Your Support
Moves Dreams
Forward