C2P2 Early Intervention 2018-2019 Application | Institute on Disabilities: Forms

Please complete and submit the application below.

Questions? Contact Cathy Roccia-Meier, Institute on Disabilities Family Education Coordinator at 215-204-1772, cathyRM@temple.edu.

To apply, please complete the form below.
Items marked with * are required.
Name*
First Last
Address
Street Address Address Line 2 City ZIP / Postal Code
Daytime Phone*
Evening Phone
Email*
We will use this email address to contact you about your application.
Enter Email Confirm Email
If you are a parent of a child/children with a disability/disabilities, please provide the following:
Age and description of child/children:
Describe Early Intervention services your child/children receive(s):
Describe preschool program (if any) your child/children receive(s):
All Applicants:
Why are you interested in participating in C2P2EI training? Did a specific issue encourage you to apply?
Are you currently employed in developmental disabilities or a related field?
- Yes
- No
Will you make a time commitment to travel and attend training in Harrisburg, PA?
- Yes
- No
Describe any special arrangements necessary for you to participate in this program?
For example: accessibility, interpreters, personal assistance services, respite, etc.
If you currently belong to any advocacy organizations, list them below:
Tell us a little about yourself and your family:
Tell us how you heard about C2P2EI:
References
List two references:
Reference 1: Full Name
Reference 1: Phone
Reference 1: Email
Reference 2: Full Name
Reference 2: Phone
Reference 2: Email

If you are a parent of a child/children with a disability/disabilities, please provide the following: