PTIC Workshop Request Form

Host Contact Info:*

If you are a school employee requesting on behalf of a SEPAC, please include a second contact from the SEPAC in the field provided below.

First Last

Phone*

For contact purposes only. Information will not be shared publicly.

Email*

Secondary Contact Info:

First Last

Phone

For contact purposes only. Information will not be shared publicly.

Email

Organization type:*

SEPAC/School District - Non-member
SEPAC/School District - MassPAC Member
Early Intervention Program
Community Based/Human Service Agency
Medical Office

If you are an Early Intervention Program, Community based/Human Service Agency or Medical Office please select "Organization (not a school district or SEPAC)" in the next field.

MassPAC Members: Which workshop benefit is this request for?*

Requesting School/SEPAC or Organization*

Organization Name:*

MassPAC Member Included Virtual Workshop request:*

MassPAC Member Bullying or Turning Three Free Virtual Workshop request:*

Virtual Workshop request:*

Preferred Date*

Secondary Date*

Preferred Start Time (A minimum of 2 hours is required):*

:

Intended Audience:*

Billing

For all School District payments, please provide Purchase Order number for invoicing:

If your school district requires a purchase order number that you do not have it at this time, please email workshops@fscn.org once you obtain the PO#. Please include your town and the requested workshop title in the subject line.

Workshop Pricing*

The Parent Training and Information Center (PTIC) has the following price levels for workshops:

If you are a current MassPAC Plus member, one workshop from our Basic Rights Series is included in your membership.

$400.00 - This is for all organizations including SEPACS, School Districts, Community Based/Human Service Agencies and Medical Offices.

$200.00 - This is for a second workshop request by a MassPAC member (any additional workshops after your second request will be invoiced at $400.00 each).

No Cost - Turning Three Essentials and Bullying: What Parents Need to Know are both provided at no cost to schools and organizations.

I agree to the above terms.

Billing Information*

First Last

Address*

Organization Street Address City State ZIP Code

Daytime Phone*

Email*

Special Notice

Special Notice: If you do not receive a confirmation email after submitting your form, your request was not received. Please attempt to resubmit using another browser and email workshops@fcsn.org to verify that we have received the request only after you submitted the request for a second time.

Billing

Special Notice

Your Support Moves Dreams Forward

Your Support
Moves Dreams
Forward