Educational Partnership Registration

Cost: Additional educators/support providers $50 for Core Program and an additional $50 for Tools for the Journey= Total $100)

Parent Name

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Student Name

Grade

School

School District

Administrator's Name

Administrator's Email

Educator's Name

Educator's Email

Independent Facilitator's Name

Independent Facilitator's Email

Financial Management Service (FMS)

Service Code

Child's UCI # (Assigned by your Regional Center)

Cardholder Name

Credit Card #

Expiration Date

Security Code

Billing Zip Code

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

Additional Educator Registration + Payment