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FCSN
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PTIC
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Parent Consultant Training Institute (PCTI)
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PCTI Registration
a
PCTI Registration
Which Training Session Would You Like to Attend? Please choose your desired class from the list below.
*
Spring: Holyoke Fridays 9:00 - 3:30 March 29 - May 31 (except April 18) 31
Summer: Sturbridge Intensive Condensed Program June 24 - 28, 2019
Contact Information
Name
*
First
Last
Home Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
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New Mexico
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone Number
*
Email
*
Accommodations
If you require any special accommodation, please describe your needs.
(we will make every reasonable effort to accommodate your needs)
Your Background
I am attending as a:
*
Parent / Parental Role
Special Education Surrogate Parent
Professional
Parent / Professional
Student (under age 26)
What is your child(ren)'s age?
What is the Ethnicity of your child with special needs?
*
Hispanic/Latino
Not Hispanic/Latino
Undisclosed
What is the Race of your child?
*
Caucasian/White
Asian
African American/Black
Native Hawaiian/Pacific Islander
American Indian/Native American/Alaskan Native
Two or more Races
Undisclosed
We need this information to maintain our Federal and State funding. No identifiable information will be shared.
What is your child's disability(ies) (Federal disability categories, please check all that apply)
*
Autism
Deaf-Blindness
Deafness
Hearing Impairment
Developmental Delay (ages 3-9)
Emotional Disturbance
Intellectual Impairment
Orthopedic Impairment (physical)
Other Health Impairment (ADHD)
Specific Learning Disability (Dyslexia)
Speech or Language Impairment
Traumatic Brain Injury
Visual Impairment-Blindness
Inappropriately identified due to lack of good instruction, environmental or economic factors, or limited English Proficiency
Disability is suspected or not yet identified
My child does not have a disability
Not disclosed
Would you like to apply for a Massachusetts Developmental Disabilities Council Empowerment Funds scholarship?
Yes
No
Individuals with developmental disabilities and family members / guardians of individuals with developmental disabilities may be eligible for PCTI scholarship totaling up to $250.
Massachusetts Developmental Disabilities Council Empowerment Funds Scholarship?
Please check all that apply:
*
I am a person with a developmental disability.
I am a family member / guardian of a person with a developmental disability.
Have you used Council Empowerment Funds before?
*
Yes
No
If yes, when?
*
*
I understand that if I do not complete the post-course follow-up survey I will be be responsible for repaying the full amount of the scholarship.
What disabilities do you work with and in what capacity?
What professional degrees, if any, do you hold:
Please describe why you wish to attend the PCTI and how it will benefit you, your family members and/or others.
*
Provide any additional information that would help us address your learning needs and expectations.
Do you speak a language other than English?
Yes
No
If Yes, what other language(s)?
Internship
As part of our Parent Consultant Training Institute (PCTI) program, we offer two optional internships designed to provide those who complete the classroom portion of the program with an opportunity to further develop and practice their advocacy skills. Our Call Center Internship consists of working 25 hours in our Call Center in Boston or the Berkshires. Our Pro Bono internship is available to those who successfully complete the Call Center Internship, and consists of providing 25 hours of free advocacy assistance to a family in need. There is no additional cost for participating in the internship. You do NOT need to decide now.
Would you like to participate in an internship?
I am interested in participating in the Internship
I am NOT interested in participating in the Internship
Tuition
Tuition for the PCTI is $350.00 for Parents, Guardians, Grandparents, and Special Education Surrogate Parents of a child with special needs and $495.00 for Professionals.
Active SESPs should contact RTSC at
rtsc@fcsn.org
or 617-399-8342 upon completion of PCTI to receive a $100 tuition rebate.
A fee of $100 will be charged for withdrawals two weeks prior to the first day of class.
No refunds will be made
for withdrawals made on or after the first day of class.
Payment
I'm registering as a:
*
Parent - $350
Professional - $495
Coupon
Total
$0.00
Credit Card (Please enter billing information exactly as it appears on your credit card statement)
*
American Express
Discover
MasterCard
Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
Expiration Date
Security Code
Cardholder Name
Billing Address:
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
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