RTSC

Please complete all applicable sections and click the submit button when you are done. If you have any issues completing the online application, please email rwilliams@fcsn.org for assistance.

Application Date*

Name*

Prefix First Last

Mailing Address

Street Address City State ZIP Code

Phone*

Phone number type

Additional phone number (optional)

Phone number type

Fax

Email*

Enter Email Confirm Email

Employer

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.

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

Parent
Educator
Educational Administrator
Attorney
Clinician
Other

Please indicate your ethnicity:

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

Describe your role/profession?

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/orientations/

Orientation Training Date

Orientation Training Location

Volunteer Information

How did you hear about the SESPP?*

*Please Specify

Please specify here:*

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

Do you speak any languages other than English?

Yes
No

If yes, please list below.*

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

Yes
No

If yes, please describe:

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:*

Are you or your spouse personally involved with the care or education of children (outside of employment or raising your own children)?*

Yes
No

If yes, please describe below:*

Would you prefer a match with a child in a particular age group(s)?*

Any age
3-6
7-12
13-16
17-22

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

Yes
No
Not Sure

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

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:

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

A reference check is required for all potential volunteers. Please list three people who know you personally or professionally and include contact information.
Do not include family members.

Reference #1*

Name	Email Address	Phone Number	Employer	Best Time to Contact

Reference #2*

Name	Email Address	Phone Number	Employer	Best Time to Contact

Reference #3

Name	Email Address	Phone Number	Employer	Best Time to Contact

Volunteer Agreement

I hereby grant permission to the Department of Elementary and Secondary Education and its contractors (the EDCO Collaborative and the Federation for Children with Special Needs) to check my references. 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.

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

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.

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How to help

Application

Special Education Surrogate Parent Volunteer Application

Online Application

DONATE NOW! How to help

Application

Special Education Surrogate Parent Volunteer Application

Online Application

RTSC

DONATE NOW!
How to help