Early Intervention Partners Training Project

Applications are due by Tuesday, August 15, 2017

Title

First Name

Last Name

Street Address

City

State

Zip / Postal Code

Home Phone

Cell Phone

Work Phone

Please select the county you live in:

Date of birth of child in Early Intervention Program

(e.g. mm/yy)

Please select the program your child is enrolled in:

	The Early Intervention Program (birth to 3 years old)
	The Preschool Program (3 years to 5 years old)
	The School-Aged Program (5 years to 21 years old)

Describe your child(ren) who has a disability (age, type of disability, and the type of program or services he/she is receiving).

Why are you interested in participating in this Early Intervention Partners Training Project?

If you are accepted for this training, how will you use the information you gain to help children and families in the Early Intervention Program?

Each county/municipality has a Local Early Intervention Coordinating Council (LEICC) comprised of parents and professionals. The purpose of the LEICC is to advise the municipality's Early Intervention Official about local early intervention issues, such as gaps in services.

If you are currently a parent member of the Local Early Intervention Coordinating Council (LEICC) in Bronx, Dutchess, Kings, Orange, Putnam, Queens, Richmond, Rockland, Sullivan, Ulster, and Westchester counties, please check here:

Please tell us about any LEICC sub-committees or workgroups you participate in:

If you are interested in becoming more involved in the LEICC, please check here:

Do you currently belong to any advocacy organizations? If so, please list:

Ethnic Background (optional)

Acceptance into the program requires a commitment to participate in all three sessions:
- Session I:
Saturday, September 16th (9:30 A.M. - 12:00 P.M.) IFSP Functional Outcomes Webinar
- Session II:
Friday, October 13th (4:00 P.M. - 9:00 P.M.) &
Saturday, October 14th (9:00 A.M. - 3:00 P.M.)
- Session III:
Friday, November 17th (4:00 P.M. - 9:00 P.M.) &
Saturday, November 18th (9:00 A.M. - 3:00 P.M.)

Are you able to commit to attending all of these training sessions?

Are you able to travel to the Radisson Hotel in New Rochelle, NY
to attend sessions II and III?

Do you need any special accommodations to participate?

If yes, please describe: (accessibility, interpreter, diet, etc.)

I understand that a requirement for acceptance to the Early Intervention Partners Training Project is my commitment to participate in all of the training sessions. If you need more information or an application form, please call Angela Furci or Liz Muller (toll-free) at 1-877-205-0502.

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