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

Daytime Phone*

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

Evening Phone:*

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

Email*

Secondary Contact Info:

First Last

Daytime Phone

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

Evening Phone:

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

Email

Organization Name*

Organization type:*

SEPAC/School District
Early Intervention Program
Community Based/Human Service Agency
Medical Office

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 three price levels for workshops.

If you are a current MassPAC Plus member, one workshop from our Basic Rights Series is included in your membership. We ask that all workshop hosts fill out the billing information but an invoice will not be sent for current MassPAC Plus members requesting the Basic Rights workshop.

$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 Plus member.

No Cost - Early Intervention programs hosting a Turning Three Essentials workshop.

Please note that if you are a current MassPAC Plus member, any additional workshops after your second request will be invoiced at $400.00 each.

I agree to the above terms.

Billing Information*

First Last

Address*

Organization Street Address City State ZIP Code

Daytime Phone*

Email*

Virtual Workshop request:*

Preferred Date*

Secondary Date*

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

:

Intended Audience:*

Language of Presentation:*

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.

Special Notice

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